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THE 


NORMAL  AND  PATHOLOGICAL 
CIRCULATION 


CENTRAL   NERVOUS   SYSTEM 

{MYEL-ENCEPHALON). 


ORIGINAL    STUDIES 


BY 

WILLIAM   BROWNING,  Ph.B.,  M.D., 

attending  neurologist  to  the  kings  county  hospital,  and  consulting  to  the 

st.  Christopher's  hospital  for  babies;  lecturer  on  normal  neurology  at 

the  long  island  college  hospital  ;  member  of  the  brooklyn  society 

for  neurology,  the  medical  society  of  the  state  of   new 

york,  the  association  of  american  anatomists,  and 

the  american  neurological  association. 


PHILADELPHIA  : 

J.  B.  LIPPINCOTT   COMPANY. 
1897. 


Copyright,  1897, 

BY 

J.  B.  Lippincott  Company. 


TO   THE   MEMORY 


OF   THE   LATE 


PROFESSOR  WILHELM   BRAUNE, 

OF  LEIPSIC, 

IN   REMEMBRANCE   OF   HIS  INVALUABLE   CONTRIBUTIONS  IN  ANATOMY, 

OF   HIS   EMINENCE  AND   KINDLY   PERSONALITY  AS   A  TEACHER, 

AND  IN  PARTICULAR  OF  THE  INCENTIVE  THAT  HE  GAVE 

THE  WRITER  TO  TAKE  UP  THIS   LINE  OF  WORK, 

THESE    VERY    IMPERFECT    CHAPTERS    ARE 

MOST   REVERENTIALLY  INSCRIBED. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/normalpathologicOObrow 


PREFACE. 


While  a  systematic  and  comprehensive  treatise  on  the 
encranial  circulation  might  be  more  generally  acceptable,  it 
is  proposed  here  to  give  only  such  special  articles  as  shall 
embody  something  of  originality.  A  portion  of  the  work 
is  a  reproduction  of  various  scattered  papers  already  pub- 
lished, but  which  are  here  used  as  a  basis  for  further  addi- 
tions. 

The  first  six  articles  are  anatomical  and  experimental ; 
the  remaining  take  up  clinical  and  pathological  topics. 

It  was  intended  to  include  some  work  on  the  normal 
pressure  in  the  dural  sinuses,  with  descriptions  of  a  new 
plan  for  measuring  the  same.  But  this  subject  has  mean- 
while been  so  fully  treated  by  Hill  that  anything  further 
thereon  seems  superfluous  at  the  present  time. 

It  is  a  pleasure  to  make  acknowledgment  of  aid  from 
many  sources.  I  must  particularize  Dr.  N.  T.  Beers  for  ex- 
cellent drawings  and  assistance,  Dr.  E.  G.  Zabriskie  for  aid 
in  most  of  the  experiments,  Mr.  Stucke  for  artistic  work, 
Professor  J.  M.  Van  Cott  and  the  Hoagland  Laboratory, 
the  late  Dr.  J.  A.  Arnold,  and  especially  Dr.  J.  T.  Duryea, 

5 


6  PREFACE. 

his  successor  as  superintendent  of  the  Kings  County  Hos- 
pital, besides  the  kind  collaborators.  And  more  especially 
am  I  indebted  to  Captain  Joseph  Ware,  of  New  York,  for 
much  trouble  and  expense  in  supplying  monkeys  from 
Mexico  for  certain  of  the  studies.  Without  these  animals, 
together  with  the  facilities  of  the  laboratory  and  of  the  hos- 
pital so  freely  placed  at  my  disposal,  much  of  this  work 
would  have  been  impossible. 

54  Lefferts  Place,  Brooklyn,  May,  1897. 


CONTENTS. 


PAGE 

I. — An  Examination  of  the  Spinal  Efferents  for  the  Cerebro-Spinal 

Fluid 9 

II. — The  Chemical  Identification  of  Cerebro-Spinal  Fluid.     By  Pro- 
fessor E.  H.  Bartley 21 

III. — The  Veins  of  the  Brain  in  the  Monkey.     With  three  Illustra- 
tions        23 

IV. — On  the  Remains  of  a  Foramen  Spheno-Temporale  in  Man  ...      30 
V. — The    Arrangement   of  the    Supra-Cerebral   Veins    in    Man,    as 
bearing  on  the  Theory  of  a  Developmental  Rotation  of  the 

Brain ^ 

VI. — On  the  Experimental  Determination  of  the  Method  of  Develop- 
ment of  Symmetrical  Brain-Hemorrhages 39 

VII. — A  Case  of  Internal  Hydrocephalus,  due  to  Disease  (Thrombotic) 

in  the  Wall  of  the  Straight  Sinus 42 

VIII. — A  Case  of  Internal   Hydrocephalus  from  Compression  of  the 

Vena  Galeni  by  a  Tubercular  Enlargement  of  the  Conarium  .      45 
IX. — A  Case  of  Traumatic  Cephalhydrocele.     With  one  Illustration    .      47 
X. — Lumbar  Puncture  for  the  Removal  of  Cerebro-Spinal  Fluid    .    .      54 
XL — A  Consideration  of  Obstructive  Hydrocephalus  and  of  the  Me- 
chanical Principles  upon  which  its  Development  depends    .    .       61 
XII. — Pseudo-Bulbar  Paralysis.     Bilateral  Apoplexy  of  the  Lenticular 

Nuclei,  simulating  Lesion  in  the  Floor  of  the  Fourth  Ventricle     103 
XIII. — A  Case  of  Symmetrically  Situated  Double  Hemorrhage  of  the 

Brain.     Reported  by  Dr.  Mark  Manley 1 12 

XIV. — On  Double  (Synchronous  and  Symmetrical)  Hemorrhages  of  the 

Brain 1 16 

7 


8  CONTENTS. 

PAGE 

XV. — Note  on  the  Occurrence  of  Brain-Hemorrhage  starting  in  a 

Focus  of  Softening 1 28 

XVI. — Cases  of  Apoplexy  following  some  time  after  Accidents  (de- 
layed  Traumatic  Hemiplegia).     With  two  Charts  ....     131 
XVII. — A  Case   suggesting   Multiple   Sclerosis,  but   due   to   Cranial 

Aneurism.     Reported  by  Dr.  F.  E.  Lambert 143 

XVIII. — Apoplexies  of  the  Brain.  The  Importance  of  Early  Treat- 
ment based  on  the  Differential  Diagnosis  of  the  Several 
Forms  (Hemorrhage,  Embolism,  Thrombosis,  Pseudo- 
Seizures)    149 


I. 


AN    EXAMINATION    OF  THE  SPINAL  EFFERENTS    FOR    THE 
CEREBRO-SPINAL    FLUID.* 

The  question  of  the  ultimate  absorbents  or  points  of 
discharge  of  the  cephalo-rachidian  fluid — those  by  which 
the  fluid  finally  leaves  the  cerebro-spinal  subarachnoid 
sac — is  a  very  important  one,  and  considerable  work  has 
been  done  in  the  direction  of  answering  it  In  connection 
with  the  subject  of  hydrocephalus  (treated  in  a  subsequent 
chapter)  it  became  necessary  to  review  our  knowledge  of 
the  matter.  This  brought  out  the  fact  that,  so  far  as  con- 
cerns the  spinal  outlets  in  man,  the  present  teaching  is 
apparently  based  on  the  results  obtained  in  animals,  and 
hence,  in  reality,  inconclusive. 

In  regard  to  the  strictly  cranial  outlets,  the  field  has  been 
repeatedly  worked  over.  The  studies  of  Key  and  Retzius, 
backed  by  Quincke,  F.  Fischer  (Waldeyer),  Kollman,  and 
others,  drew  attention  to  the  Pacchionian  bodies  as  impor- 
tant paths  of  discharge  (like  overflow  taps).  Though  this 
view  has  not  met  with  universal  acceptance,  and  so  good 
an  observer  as  Trolard  (1892)  decides  positively  against  it, 
the  evidence f  in  its  favor  is  very  strong.     The  great  increase 

*  Read  before  the  Association  of  American  Anatomists  at  the  Washington 
meeting,  May  5,  1897. 

f  Reiner  and  Schnitzler's  experiments  with  the  absorption  of  ferrocyanide 
of  potash  and  also  of  oil  from  the  subarachnoid  space  (Wien,  1894,  v.  Neurlgc. 
Cntbl.,  1895,  P-  J9)  showed  that  it  reached  the  venous  current  within  the 
skull.     Their  supposed  stomata  may  as  well  be  the  Pacchionian  absorbents. 

9 


IO  CENTRAL  NERVOUS   SYSTEM. 

of  these  bodies  in  adult  life  has  militated  against  this  theory. 
But  the  results  to  be  described  in  this  paper  offer  a  better 
understanding  of  the  relation. 

More  certain  efferents  are  the  sheaths  of  outgoing  cranial 
nerves.  Along  the  optic  the  space  extends  to  the  bulbus. 
Connections  of  this  kind  have  been  shown  with  the  cellular 
tissue  in  the  nasal  cavity.  And  other  similar  paths  have 
been  described.  The  proof  that  absorption  by  these  routes 
actually  occurs  was  furnished  not  only  by  injections  on  the 
cadaver  but  also  by  the  special  deposits  of  suspended  par- 
ticles injected  in  animals. 

The  recent  claims  by  L.  Hill,  of  a  more  general  filtra- 
tion off  of  the  fluid,  can  hardly  apply  to  conditions  as  we 
meet  them  in  practice. 

In  any  case  the  tendency  of  the  fluid  in  bipeds  is  to  sink 
by  gravity  into  the  spinal  sac,  and  from  there  find  some 
way  out,  even  if  it  has  to  do  this  by  returning  again  to  the 
cranial  cavity.  The  effect  of  gravity  on  the  position  of 
this  fluid  was  long  since  shown  by  Luschka  ("Aderge- 
fiechte  d.  Mensch.  Gehirns,"  1855,  p.  73). 

Most  of  the  published  studies  on  the  absorption  of  this 
fluid  in  man  have  been  devoted  to  the  cranial  efferents. 
Possibly  previous  workers  have  not  caught  the  clue  that  is 
afforded  by  the  change  in  the  human  from  fcetal  to  post- 
natal conditions.  There  is,  then,  the  more  reason  for  ex- 
tending our  knowledge  of  this  subject  as  regards  the  spinal 
efferents,  and  it  is  wholly  to  this  phase  of  the  question  that 
the  present  experiments  have  been  devoted. 

My  injections  of  the  spinal  subarachnoid  space  have 
usually  been  made  from  the  cervical  or  top-dorsal  region, 
and,  of  course,  directed  caudad.  The  material  used  has 
been   either  the   customaiy  solution   of  Prussian   blue   or 


CENTRAL  NERVOUS   SYSTEM.  II 

Loeffler's  aqueous  alkaline  solution  of  methyl  blue,  suitably 
diluted.  It  is  necessary  to  employ  a  liquid  with  distin- 
guishable color,  and  yet  free  from  floating  particles.  Va- 
rious degrees  of  pressure  have  been  exerted,  but  a  mod- 
erate force  accomplishes  quite  as  much  as  more,  and  is 
less  open  to  criticism. 

The  following  description  is  based  on  the  results  ob- 
tained by  a  series  of  injections  practised  on  the  bodies  of 
two  monkeys  and  one  cat,  on  four  fcetal  subjects,  and  on 
the  cadavers  of  six  humans  ranging  in  age  from  a  month- 
old  infant  all  the  way  up  to  nearly  seventy  years. 


IN    ANIMALS. 

As  monkeys  are  partly  bipeds,  they  offer  the  best  analogy 
to  man  in  this  respect  also.  In  their  upright  position  gravity 
sends  the  fluid  down  the  spine  by  preference.  Both  these 
animals  were  full-grown,  though  young  and  healthy.  The 
one  was  supposed  to  be  about  thirteen  months  and  the 
other  sixteen  months  old  when  used.  The  injections  were 
made  while  the  body  was  still  warm,  and  hence  before  the 
possible  interference  of  post-mortem  changes, — a  better 
guarantee  of  natural  conditions  than  can  often  be  secured 
in  the  human.  With  each,  after  removal  of  the  head,  the 
inverted  trunk  was  hung  up  long  enough  to  empty  the 
vertebral  canal  as  much  as  possible  of  all  fluids. 

As  in  neither  did  the  injection  pass  out  beyond  the  root 
ganglia  along  any  of  the  costal — i.e.,  proximal — nerves,  it  is 
clear  that  any  moderate  pressure  used  did  not  force  false 
passages. 

This  was  further  shown  in  the  one  positive  case  by  the 
gradually  lessening  depth  of  color  along  the  cord,  away 


12  CENTRAL   NERVOUS   SYSTEM. 

from  the  point  of  injection.  Section  of  the  roots  showed 
the  color  in  the  surrounding  sheath  only. 

In  one  of  these  animals — the  one,  too,  where  the  greater 
pressure  was  used,  and  where  the  material  passed  more 
completely  down  to  the  termination  of  the  arachnoid  sac 
in  the  cauda  equina — the  color  did  not  at  any  point  extend 
out  beyond  the  root  ganglia. 

In  the  case  of  the  other  (younger)  monkey  the  findings 
were,  for  the  most  part,  the  same.  Only  at  one  point  was 
there  anything  calling  for  further  mention.  On  following 
out  peripherally  the  large  lumbars  one  pair  of  nerves  (the 
third  lumbar?)  was  found,  each  of  which  showed  the  fol- 
lowing :  Well  beyond  the  ganglion  and  quite  outside  the 
vertebrae,  on  the  upper  side  of  (cephalad)  but  not  surround- 
ing the  nerve,  was  a  little  blue  pouch.  The  two  were  the 
same  in  appearance,  were  equidistant  from  the  cord,  and 
each  extended  along  the  nerve  about  one-half  centimetre. 
The  channel  by  which  the  solution  had  reached  this  was 
not  discovered,  though  it  was,  doubtless,  along  the  nerve- 
sheath.  The  distance  from  the  point  of  injection,  together 
with  the  considerable  obstruction  and  but  moderate  press- 
ure used,  must  have  prevented  the  forcing  of  any  false 
passage.  Moreover,  the  symmetrical  arrangement  of  these 
small  spaces  precluded  any  suspicion  of  artefact.  Here 
was  an  extra-vertebral  extension  or  connection  of  the  regu- 
lar subarachnoid  space,  evidently  an  outlet  for  cerebro- 
spinal fluid. 

As  the  younger  animal  even  did  not  show  as  ample 
spinal  exits  as  either  dogs  or  the  human  foetus,  while  the 
older  one  failed  to  show  any  at  all,  it  is  easy  to  conclude 
that  in  them  the  spinal  efferents  were  in  the  stage  of  closing 
up.      The   monkey  seems   to   correspond   partly  to   man, 


CENTRAL  NERVOUS   SYSTEM.  1 3 

representing  an  intermediary  course  between  him  and 
lower  animals.  At  the  same  stage  in  the  individual 
monkey's  development  these  passages  are  only  less  com- 
pletely closed  than  in  the  human. 

In  the  case  of  a  large  two-year-old  cat  the  injection  failed 
to  pass  very  freely  down  the  whole  length  of  the  cord. 
Yet  it  did  run  out  along  the  third  lumbar  nerve  for  a  short 
distance  into  the  muscles  at  the  back  of  the  abdominal 
cavity. 

Quincke  ("Zur  Physiologie  der  Cerebrospinalflussigkeit," 
reprinted  from  Dufrois-Reymond' s  Archiv,  1872),  from  ex- 
perimental injection  of  cinnabar-emulsion  into  the  spinal 
subarachnoid  space  of  living  dogs,  found  that  "  In  several 
cases  the  cinnabar  could  be  followed  on  the  lumbar  nerves 
to  the  region  of  the  lumbar  plexus  between  the  origins  of 
the  psoas,  as  well  as  in  the  sciatic  plexus  beyond  its  en- 
trance into  the  pelvis." 

And  Key  and  Retzius  {Arch.  f.  Mikroskop.  Anat.,  1873, 
Bd.  ix.),  in  Fig.  39,  picture  the  injection  of  the  sacro-lumbar 
plexus  from  the  spinal  subarachnoid  in  the  dog. 

IN    THE    HUMAN. 

The  subjects  of  post-natal  age  covered  the  whole  period 
of  life,  and  were  essayed  in  the  following  order  : 

1.  Female  of  about  sixty-eight  years  ;  dead  of  dysentery. 

2.  Female  of  forty-nine  years  ;  erysipelas  and  pulmonary 
sequel. 

3.  Female  of  twenty-six  years ;  syphilitic  disease  in  pons. 

4.  Male  child  of  six  months. 

5.  Male  infant  of  two  months  and  ten  days  ;  marasmus. 

6.  Female  infant  of  premature  birth,  that  had  lived 
twenty-four  days. 


14  CENTRAL   NERVOUS   SYSTEM. 

Of  course,  only  unfrozen  cadavers  are  of  use,  and  the 
fresher  the  better.  With  the  exception  of  the  two  youngest 
subjects,  the  findings  in  the  series  were  so  uniform  that  one 
description  covers  all. 

On  incising  the  arachnoid  there  was  always  an  outflow 
of  free,  clear  fluid.  Its  discharge  was  assisted  by  tempo- 
rary inversion,  leaving  a  collapsed  sheath.  This  last  ap- 
pears to  become  more  fully  distended  to  a  wide  canal  in 
old  subjects. 

Each  was  injected  from  the  cervical  region.  The  ample 
filling  of  the  space  all  the  way  down  showed  that  sufficient 
pressure  had  been  transmitted  to  all  parts.  The  whole 
cordon  of  roots  on  each  side  was  then  exposed.  These 
showed  the  blue  color  as  far  as  the  root  ganglia,  but  never 
and  at  no  point  beyond.  Sometimes  the  nerves  at  the 
back  of  the  abdominal  and  pleural  cavities  were  first  exam- 
ined before  cutting  away  the  vertebral  arches,  but  the  find- 
ings were  the  same. 

The  root  ganglion  was  never  blued  to  any  extent,  and 
only  on  its  central  side.  On  the  anterior  root,  as  specially 
noted  by  Dr.  Beers,  the  color  did  not  extend  quite  as  fully 
or  far  peripherally  as  on  the  posterior, — the  limitation  of 
each  taken  together  constituting  an  oblique  line. 

The  result  in  the  subject  of  two  months  and  ten  days 
differed  but  slightly  from  that  in  the  older  ones  as  just 
outlined.  Several  drops  of  clear  fluid  ran  off  on  incising 
the  arachnoid.  It  was  injected  from  the  mid-dorsal  region. 
No  blue  was  found  anywhere  by  tracing  up  the  nerves  cen- 
tripetally  to  the  vertebrae.  And  on  following  out  the  roots 
from  the  cord  the  color  was  found  to  go,  as  usual,  just  to 
the  root  ganglia,  except  along  two  corresponding  roots  on 
each  side, — the  first  and  second  lumbars.     These  all  showed 


CENTRAL   NERVOUS   SYSTEM.  1 5 

the  same  condition.  The  posterior  roots,  barely  as  far  as 
the  ganglia,  were  fully  blued  as  usual.  Each  anterior  root, 
however,  showed  a  couple  of  distinct  but  rather  fine  blue 
lines,  reaching  by  and  about  three  millimetres  beyond  the 
termination  of  the  ganglion.  The  blue  in  each  stopped 
just  there.  Hence,  evidently,  a  little  stump  of  the  foetal 
absorbent  was  not  yet  obliterated. 

The  youngest  subject  of  this  series  was  an  infant  born  at 
about  the  seventh  month  of  pregnancy,  and  that  had  lived 
twenty-four  days  (weight,  two  and  three-fourths  pounds  ; 
at  birth,  three  pounds).  Used  thirteen  hours  post-mortem. 
Here  again  injection  showed  but  slight  difference  from  the 
adult.      No  free  fluid  on  opening  the  spinal  arachnoid. 

The  right  ileo-hypogastric  nerve  showed  on  its  ventral 
aspect  a  single  distinct,  slightly  sinuous  blue  line,  quite 
like  a  minute  vessel,  that  extended  about  one  centimetre 
peripherally  from  the  root  ganglion  and  came  down  the 
anterior  root.  The  anterior  crural  roots  (middle  and  upper 
primary  trunks)  on  each  side  were  more  or  less  blue  in  the 
surrounding  sheaths  to  just  beyond  the  exit  from  the  verte- 
bral column,  but  not  farther. 

As  this  infant  had  not  reached  the  usual  age  at  birth 
(from  time  of  conception),  and  yet  had  lived  some  weeks, 
the  findings  are  interesting.  The  outlets  had  become  al- 
most, though  not  quite  fully,  closed  up.  This  indicates 
that  the  obliterating  process  is  a  natural  result  of  post- 
uterine  living. 

IN    THE    FCETUS. 

There  were  four  subjects  from  this  period,  corresponding 
to  the  sixth  and  seventh  months  of  pregnancy,  respectively, 
— not,  of  course,  including  the  premature  infant  described 
last  above.     The  results  of  these  fcetal  injections  were  so 


1 6  CENTRAL   NERVOUS   SYSTEM. 

similar  to  each  other  that  they  also  can  be  summarized 
together.  In  each  the  outcome  was  positive.  For  first 
study  of  the  whole  cord  the  injection  was  made  from  the 
cervical  region.  But,  to  obtain  the  best  results,  the  cannula 
in  two  was  inserted  in  the  dorsal  region. 

The  appearance  of  the  nerves  above  the  lumbars  (i.e., 
of  the  dorsals  and  cervicals)  was  the  same  as  in  all  the  post- 
natal subjects.  There  was  no  extension  of  the  material 
along  these  beyond  the  root  ganglia,  and  neither  was  there 
any  bluing  of  the  nerves  from  the  extremity  of  the  cord, 
including  the  sciatics. 

The  direction  of  the  efferents  was  found  to  be  invariably 
towards  the  abdominal  cavity.  The  roots  and  trunk  of  the 
anterior  crural  nerve  are  the  main  paths,  and  along  these  the 
material  may  pass  well  down  into  the  pelvis.  In  one  case 
the  nerves  that  follow  around  the  flank  (ileo-hypogastric, 
etc.)  had  participated.  In  one  there  was  considerable  diffuse 
bluing  of  the  psoas  muscle  towards  its  insertion  (indicating 
that  the  material  had  escaped  from  any  direct  arachno- 
spinal  extensions),  in  this  respect  corresponding  to  an  ob- 
servation on  the  dog  above  cited. 

Not  even  in  these  fcetal  examples  have  the  sciatics  ever 
shown  any  injection,  though  in  animals  such  a  result  has 
been  described. 

DISCUSSION. 

My  results,  taken  together  with  the  facts  previously 
known,  lead  to  a  very  definite  conclusion,  and  one  with 
which  they  all  harmonize  completely. 

Outlets  for  the  cerebrospinal  fluid  exist  along  the  lumbar 
nerves  in  the  lower  animals  at  all  ages,  but  in  the  human  only 
during  foetal  or  uterine  life.  The  monkey  may  represent 
an  intermediary. 


CENTRAL  NERVOUS   SYSTEM.  1 7 

This  wide  difference  between  animal  and  living  human 
conditions,  as  well  as  between  foetal  and  post-natal  in  man, 
does  not  appear  to  have  ever  been  recognized. 

Numerous  points  that  call  for  discussion  immediately 
suggest  themselves,  and  can  in  part  be  answered  here. 

i.  Are  these  nerve-sheath  extensions  of  the  spinal  sub- 
arachnoid space  real  exits  for  the  fluid  ? 

This  is  shown  with  reasonable  certainty  by  the  results  of 
simple  injection. 

It  has  further  been  repeatedly  shown  by  a  scattering  of 
the  injected  material  in  the  upper  part  of  the  psoas  muscle 
(for  the  dog,  by  previous  workers  ;  in  the  human  fcetus,  by 
my  own  injection). 

It  is  again  proven  by  the  special  deposit  here  of  sus- 
pended material  injected  about  the  cord.  Of  course,  the 
result  of  such  experiments  applies  to  all  cases  where  the 
passages  are  otherwise  known  to  exist,  even  though  it  is 
only  possible  to  carry  them  out  on  an  animal. 

That  a  minimal  amount  of  absorption  may  occur  per  the 
parietes  of  the  spinal  sac  itself  is  possible,  but  it  cannot  be 
material. 

2.  At  what  time  does  this  obliteration  of  the  spinal  exits 
in  man  occur? 

It  has  not  begun  up  to  birth,  and  yet  is  practically  com- 
plete by  the  time  the  infant  is  two  and  a  half  months  old. 
In  fact,  this  result  is,  reasoning  from  the  case  of  premature 
birth,  probably  reached  in  full-term  cases  by  the  end  of 
the  first  month,  and  even  earlier.  My  cases  show  that  this 
transition  is  not  an  instantaneous  process,  but  one  that  it 
takes  a  little  time  to  complete.  It  must  begin  very  shortly 
after  if  not  directly  from  birth,  and  constitutes  one  of  the 
earliest  changes  of  extra-uterine  life. 


S 


1 8  CENTRAL  NERVOUS   SYSTEM. 

There  may  well  be  some  individual  difference  in  this  re- 
gard. Though  there  is  no  evidence  of  persistent  remains 
of  this  sort,  it  would  be  strange  if  such  never  occurred. 

3.  How  is  this  obliteration  effected,  and  to  what  agencies 
is  it  due  ? 

From  the  observations  in  animals,  my  partial  result  in 
the  monkey,  my  positive  in  the  foetal,  but  negative  in  older 
human  subjects,  it  is  apparently  demonstrated  that  the  up- 
right position  in  man  is  the  main  factor  in  shutting  off  the 
lower  or  spinal  absorbents. 

It  may  be  objected  to  this  that  these  efferents  close  up 
in  early  infancy,  and  hence  before  the  upright  position  has 
been  to  any  extent  assumed.  So  far  as  concerns  the  im- 
mediate mechanism  of  closure,  this  may  be  true.  But  it 
is  explained  by  the  corresponding  fact  that,  while  all  the 
lower  animals,  old  or  young,  rest  and  sleep  on  their  bellies, 
the  human  infant  sleeps  and  lives  altogether  on  its  back, 
or  at  most  but  slightly  over  on  its  side, — a  reversal  of  the 
conditions  of  intra-abdominal  pressure.  Very  likely  this 
change  in  pressure  about  the  lines  of  exit  plays  the  impor- 
tant part.  The  result  in  the  infant  of  two  months  shows 
that  the  primary  closure  of  the  exits  is  not  as  far  up  as  is 
the  final,  and  this  indicates  some  agency  ventrad  of  the 
spinal  column. 

Or  there  may  be  other  and  less  mechanical  morpho- 
logical factors  at  work. 

In  the  place  of  the  spinal  efferents  the  arachnoidal  villi 
and,  perhaps,  the  other  cranial  outlets  increase  as  life  ad- 
vances and  afford  adequate  substitutes. 

It  is  worth  noting  that  these  spinal  efferents  apparently 
run  out  chiefly  along  the  anterior  roots,  and  that  as  they 
close  up  we,  for  a  time,  find  as  temporary  remnants  certain 


CENTRAL  NERVOUS   SYSTEM.  1 9 

fine  passages  that  have  all  the  appearance  of  distinct  ves- 
sels.     Finally  these  also  disappear. 

4.  This  knowledge  helps  to  explain  a  number  of  matters. 
It  presumably  has  some  bearing  on  the  occurrence  of  lum- 
bar spina  bifida,  and  on  the  frequent  development  of  hy- 
drocephalus after  its  removal.*  It  throws  the  onus  of  the 
congenital  form  of  hydrocephalus  on  the  lumbar  region  ;  it 
harmonizes  with  the  increase  of  arachnoidal  villi  in  adult 
life  ;  it  shows  how  the  cushion  of  arachnoidal  fluid  about 
the  cord,  at  the  base  of  the  brain,  etc.,  is  supported, — i.e., 
prevented  from  leaking  off.  As  this  last  is  a  very  impor- 
tant safeguard  or  protector  of  the  brain  in  man,  we  see  how 
essential  a  factor  in  the  change  of  body-position  to  the  up- 
right must  be  this  coordinate  or  preliminary  closing  up  of 
the  spinal  outlets. 

This  free  column  of  water  about  the  cord  in  the  adult 
means  a  considerable  hydrostatic  pressure  on  the  lower 
spinal  structures,  approximately  a  pound  to  the  square  inch 

*  An  interesting  point  is  the  possible  purpose  of  such  arachnoceles  as  occur 
in  spina  bifida,  meningocele,  traumatic  hydrencephalocele,  etc.  That  such 
pouches  serve  as  special  absorbent  diverticula  for  the  fluid  is  suggested  by 
various  facts. 

Not  rarely  a  spina  bifida  is  accompanied  by  some  hydrocephalus.  Or 
often  the  removal  of  such  a  tumor  is  followed  by  the  development  of  resp. 
an  increase  of  a  hydrocephalus. 

Similarly  with  the  cranial  forms,  there  are  cases  like  the  following  :  A  small 
meningocele  just  at  the  base  of  the  occiput  was  removed  successfully  from  a 
child  some  time  after  birth.  Directly  thereafter  hydrocephalus  began  to  de- 
velop, of  which  previously  there  had  been  no  evidence. 

Now,  it  is  not  probable  that  the  operative  or  cicatricial  contraction  shuts  off 
the  normal  discharge,  since  in  the  spinal  type,  at  least,  there  are  no  longer 
important  local  absorbents  to  be  affected.  But  if  their  walls  can  absorb,  then 
it  is  clear  that  their  removal  might  have  such  effect.  This  also  makes  it  ex- 
plicable why  hydrencephaloceles  sometimes  show  a  tendency  to  shrink, — this 
occurring  if  other  and  more  natural  outlets  develop. 


20  CENTRAL   NERVOUS   SYSTEM. 

in  an  average  male  when  upright  The  daily  recumbency 
of  sleep  goes  far  towards  delaying  untoward  consequences. 
While  the  healthy  and  vigorous  may  experience  no  effects 
therefrom,  in  the  feeble  and  senile  the  finer  nutrition  of 
the  yielding  structures  of  the  lower  cord  and  its  roots  may 
indeed  suffer.  This  suggests  itself  as  one  cause  for  certain 
cases  of  senile  paraplegia,  in  which  the  upper  extremities 
are  fairly  intact. 

[Despite  the  ample  material  available,  it  has  not  been 
possible  to  secure  a  full-term  foetus  for  this  purpose.  To 
that  extent  this  line  of  investigation  is  as  yet  unavoidably 
incomplete.] 


II. 


THE     CHEMICAL      IDENTIFICATION     OF      CEREBRO-SPINAL 

FLUID.* 

The  cerebro-spinal  fluid  differs  from  other  serous  fluids 
in  chemical  composition  to  such  an  extent  that  it  may  be 
differentiated  from  them  by  simple  chemical  tests.  This 
fluid  ought  to  be  regarded  as  a  true  secretion  rather  than 
as  an  exudate. 

The  fluid,  when  pathologically  increased  in  quantity,  does 
not  usually  depart  from  the  normal  composition.  After 
tapping  a  sac  filled  with  cerebro-spinal  fluid  a  number  of 
times  there  is  apt  to  be  some  inflammatory  exudate  (or 
transudation),  which  partakes  of  the  properties  of  other 
serous  or  inflammatory  exudates.  Cerebro-spinal  fluid 
contains  but  traces  of  serum  albumin,  the  proteids  being 
usually  in  the  form  of  albumoses. 

There  is  usually  present  no  fibrinogen  ;  hence,  this  fluid 
does  not  clot. 

All  the  proteids  of  cerebro-spinal  fluid  are  precipitable 
by  saturating  the  solution  with  magnesium  sulphate.  Serum 
albumin  is  not  precipitated  by  this  salt,  and  hence  must  be 
absent. 

Sometimes  there  is  found  a  specimen  which  gives  a  small 

*  By  Elias  H.  Bartley,  B.S.,  M.D.,  Professor  of  Chemistry  at  the  Long 
Island  College  Hospital,  from  his  paper  in  the  Jotirnal  of  Nervous  and 
Mental  Disease  for  1893. 

21 


22  CENTRAL  NERVOUS   SYSTEM. 

amount  of  serum  albumin  coagulum  on  boiling.  The  al- 
bumoses  are  precipitated  by  cold  nitric  acid,  but  the  co- 
agulum dissolves  on  warming,  to  reappear  on  cooling. 

The  specific  gravity  of  cerebro-spinal  fluid  is  generally 
lower  than  that  of  other  serous  fluids.  It  ranges  from 
1005  to  1010.  The  albumoses,  like  peptones,  give  the 
biuret  reaction,  or  pink  color,  with  Fehling's  solution. 
Cerebro-spinal  fluid  reduces  Fehling's  solution,  owing  to 
the  presence  of  a  substance  believed  to  be  pyrocatechin. 

To  apply  these  facts  to  the  practical  examination  of  a 
suspected  fluid  we  may  proceed  as  follows  : 

1.  Boil,  when  there  should  be  not  more  than  a  trace  of 
coagulum  of  serum  globulin  and  serum  albumin. 

2.  Cold  nitric  acid  ought  to  form  a  precipitate,  which 
disappears  on  heating,  and  separates  again  on  cooling. 

3.  Saturation  with  magnesium  sulphate  should  give  a 
precipitate.  Saturation  with  sodium  chloride  should  also 
produce  a  precipitate.  Ammonium  sulphate  may  be  tried, 
if  the  above  salts  fail. 

4.  The  solution  floated  upon  Fehling's  solution  should 
give  a  pink  or  rose-red  zone  at  the  line  of  contact. 

5.  When  boiled  with  Fehling's  solution,  there  should  be 
a  reduction  of  the  copper — pyrocatechin. 

6.  The  specific  gravity  should  be  between  1005  and 
IOIO. 

In  repeated  tappings,  the  later  ones  give  inflammatory 
products  with  serum  albumin,  together  with  the  albumoses, 
— i.e.,  they  coagulate  with  heat  and  nitric  acid. 


III. 

THE  VEINS    OF  THE    BRAIN   IN   THE    MONKEY. 

As  these  animals  are  so  important,  both  for  experimental 
and  comparative  study,  it  is  desirable  to  have  a  thorough 
knowledge  of  their  encranial  circulation.  So  far  as  con- 
cerns the  arteries,  the  field  has  been  repeatedly  traversed. 
Through  the  courtesy  of  the  author  I  have  had  Rojecki's 
work  for  comparison  ("Sur  la  Circulation  arterielle  chez 
le  Macacus  cynomolgus  et  le  Macacus  sinicus,"  reprinted 
from  J  ml.  de  V  Anatomic,  1891). 

On  the  venous  side  special  descriptions  seem  to  be  want- 
ing. The  chief  subject  used  for  this  study  was  a  full-grown 
male  Mexican  monkey  {Ateles  geoffroii).  At  the  instance 
of  Dr.  Van  Cott  the  following  plan  was  adopted  to  free 
the  head-vessels  as  much  as  possible  from  blood,  and  so 
avoid  the  formation  of  obstructing  clots. 

The  animal  was  chloroformed  ;  both  carotids  were  ex- 
posed while  yet  pulsating,  and  ligatures  loosely  adjusted. 
The  one  on  the  left  was  tied,  a  slit  cut  in  the  vessel  just 
cephalad,  and  a  cannula  bound  in.  While  normal  salt 
solution  was  injected  through  this,  the  right  carotid  was 
tied  and  severed  just  above.  By  this  means  there  was  a 
free  back-flow  from  the  latter  vessel,  and  the  internal 
carotid  system  was  supplied  wholly  with  salt  solution. 
Were  it  not  for  the  lesser  vertebrals  this  method  would 
soon  exsanguinate  the  whole  brain.     As  it  was,  the  con- 

23 


24  CENTRAL  NERVOUS   SYSTEM. 

ditioif  found  on  exposing  that  organ  showed  that  the  plan 
had  succeeded  well  so  far  as  concerned  the  carotid  distribu- 
tion. 

After  death  of  the  animal  the  head  was  removed,  right 
carotid  clamped,  vessels  further  washed  out,  and  for  a  brief 
period  the  alinjection  of  Wilder  practised.  Permanent  in- 
jection of  the  veins  some  hours  later. 

The  following  description  is  based  principally  on  this 
specimen,  though  a  second  brain,  injected  centrally,  was 
also  used  to  decide  some  features  more  fully  : 

1.  On  cutting  away  the  scalp  two  small  symmetrical 
venous  foramina  were  noted  in  occipital  bone  near  median 
line. 

2.  No  emissaria  Santorini  found  in  parietal  bones,  nor 
did  any  appear  when  injecting  later. 

3.  Length  of  denuded  skull,  three  and  one-fourth  inches  ; 
breadth,  two  and  one-half  inches. 

4.  Moderate  amount  of  diploe,  and  sutures  everywhere 
firmly  united. 

5.  The  anterior  lobes  were  much  paler  than  the  occipital, 
the  latter  still  showing  some  blood  in  the  veins.  This  dif- 
ference was,  of  course,  due  to  the  saline  solution  injected 
into  the  carotid  ( Vide  supra). 

6.  Torcular  opened.  Cannula  inserted  forward  in  long 
sinus,  and  colored  starch  solution  injected  (after  cutting 
away  calvarium  with  ronguer,  but  with  dura  otherwise 
intact).  The  superior  veins  filled  promptly  and  well,  as 
could  be  seen  through  the  transparent  dura. 

7.  The  straight  sinus  was  found  to  empty  directly  at  the 
torcular,  though  a  slight  fold  of  dura  turned  the  current 
wholly  into  the  right  lateral.  The  long  sinus  connected 
with  both  laterals,    but  also   turned    principally  into   the 


CENTRAL   NERVOUS   SYSTEM.  25 

right.  In  the  second  specimen,  however,  the  long  sinus 
turned  more  into  the  left  lateral  and  the  straight  sinus  into 
the  right. 

8.  To  fill  the  ventricular  veins,  my  old  plan  was  em- 
ployed {y.  "Veins  of  Brain,"  pp.  44,  45).  After  cutting 
away  the  skull-cap  and  loosening  the  dura,  but  before 
taking  out  the  brain,  the  head  is  inverted.  The  internal 
vessels  are  thus  relieved  of  all  compression.  Starch  solu- 
tion is  then  injected  through  the  sinus  rectus.  This  sus- 
pension, together  with  the  washing  out  intra  vitam  with 
normal  solution,  constitutes  a  very  perfect  experimental 
method  of  injecting  the  central  vessels  of  the  brain.  Where 
such  a  scheme  can  be  carried  out  entire  success  is  assured. 

9.  Foramen  of  Magendie  freely  open. 

SUPRA-CEREBRAL   VEINS.     (Plate  I.,  Fig.  1.) 

There  was  a  noticeable  grouping  of  these  vessels  into  an 
anterior  set  composed  of  four  pairs,  and  a  posterior  of  four 
or  five  pairs.  On  the  right  this  was  more  apparent  than 
real,  as  was  shown  on  drawing  away  the  falx.  A  like 
grouping  occurs  in  man. 

Those  of  the  anterior  set  are  scattered  along  some  dis- 
tance apart,  while  the  posterior  ones  are  at  their  mouths 
much  more  bunched. 

There  is  no  indication  on  either  side  of  a  so-called  vena 
anastomotica  magna.  This  term  was  applied  by  Trolard 
to  a  supra-cerebral  often  larger  than  the  others,  and  that 
seemed  to  offer  a  special  communication  between  the 
middle  of  the  longitudinal  sinus  above  and  veins  in  the 
Sylvian  region  emptying  below.  The  writer  has  pointed 
out,  however,  that  little  importance  can  be  attached  to  this 
vessel  even  in  man. 


26  CENTRAL   NERVOUS   SYSTEM. 

The  supra-cerebrals  from  the  frontal  region  show  a  trifling 
turn  backward  just  as  they  near  the  sinus,  thus  agreeing 
with  their  course  in  man  and  most  animals.  Those  more 
posteriorly,  however,  turn,  vice  versa,  slightly  forward  on 
approaching  the  sinus,  yet  to  a  decidedly  less  extent  than 
they  do  in  the  human. 

OTHER    SUPERFICIAL   VEINS. 

1.  On  the  left  three  veins,  and  on  the  right  two,  jumped 
from  the  lower  border  of  the  occipital  lobe  to  join  the  lat- 
eral sinus. 

2.  On  each  side  a  large  vein  was  seen  to  reach  the 
dura  by  leaving  the  tip  or  frontal  border  of  the  first  tem- 
poral convolution.  This  vessel  then  ran  directly  outward, 
under  the  dura,  along  the  bony  crest  (sphenoid  wing),  and 
straight  through  the  skull  into  the  temporal  region  just 
back  of  the  upper  level  of  the  orbit,  (v.  Plate  II.,  Fig.  3.) 
It  originated  from  surface  vessels  of  the  temporal  lobe. 
The  injection  could  be  followed  to  the  outside  of  the  skull, 
and  without  any  diminution  in  the  size  of  the  vessel.  This 
shows  it  to  be  a  true  emissary,  and  one  that  in  the  monkey 
drains  a  considerable  portion  of  the  temporal  lobe. 

There  is  often  in  the  human  a  partial  counterpart  to  this. 
A  considerable  vein  from  the  temporal  lobe,  and  sometimes 
a  partner  from  the  adjacent  portion  of  the  frontal,  either 
passes  under  the  sphenoid  wing  to  reach  the  cavernous 
sinus  (as  has  been  supposed),  or  more  rarely  runs  in  the 
dura  around  under  the  temporal  lobe,  across  the  whole 
middle  fossa,  to  reach  the  supra-petrosal  sinus. 

The  orifice  by  which  this  vessel  in  the  monkey  leaves 
the  skull,  and  which  is  essentially  for  its  transit,  is  certainly 
not  the   "  Foramen   orbito-temporale    der   amerikanischen 


CENTRAL   NERVOUS   SYSTEM.  27 

Affen"  described  by  De  Filippi  in  1865.  And  with  equal 
certainty  it  is  not  the  emissarium  temporale  *  of  Luschka. 
In  fact,  it  does  not  seem  to  have  been  specially  recognized, 
and  may  fairly  be  called  new. 

As  this  opening  is  through  the  sphenoid  ala  to  the  ex- 
ternal temporal  fossa,  it  may  be  in  order  to  suggest  the  term 
"Foramen  spheno-temporale"  as  a  proper  characterization. 

3.  The  cranial  dura  runs  down  between  the  orbitae  to 
connect  directly  with  the  tissue  of  the  nose.  The  sinus 
injection  went  in  a  fine  stream  as  far  as  the  cranial  limit, 
and  evidently  had  slight  connections  through  this  foramen 
caecum. 

4.  There  was  no  trace  of  an  infra-longitudinal  sinus  in 
either  specimen  (infrequent  even  in  man).  But  instead 
there  was  a  large  azygos  supra-callosal  vein.  This  could 
be  followed  two-thirds  of  the  way  along  the  dorsum  of  the 
callosum  in  the  median  line,  ending,  as  does  the  smaller 
vein  in  man,  posteriorly  in  the  vena  Galeni.  This  received 
numerous  branches  on  either  side,  running  up  to  the  mar- 
ginal fissure  and  connecting  more  or  less  freely  with  the 
descending  median  branches  of  the  supra-cerebral  veins 
(also  like  the  same  in  man). 

*  As  E.  Loewenstein  puts  it  in  his  thesis  ("  Ueber  das  Foramen  jugulare 
spurium  und  den  Canalis  temporalis  am  Schadel  des  Menschen  und  einiger 
Affen,"  Konigsberg,  1895),  "  The  canalis  temporalis  is  during  the  embryonic 
period  the  way  by  which,  through  connection  with  the  sirtus  transversus  and 
the  sinus  petroso-squamosus,  the  blood  is  carried  from  the  skull  to  the  exter- 
nal jugular  vein."  He  found  some  remaining  trace  of  this  foramen  jugulare 
spurium  on  one  side  or  the  other  in  hardly  one  out  of  ten  human  skulls. 

In  monkeys  he  found  that,  of  the  Catarrhines,  it  was  not  present  in  nine 
Cercopithecus  skulls,  in  six  Cynocephalus,  nor  in  three  Semnopithecus,  but 
could  be  made  out  in  eleven  Inuus  ;  of  the  Platyrrhines,  it  was  regularly  pres- 
ent in  three  Ateles  skulls,  in  five  Cebus,  in  three  Mycetes,  and  in  four  Hafale. 

He  sums  up  that  in  this  respect  the  monkey  resembles  man. 


28  CENTRAL   NERVOUS   SYSTEM. 

5.  A  large  internal  occipital  vein  also  helped  to  form 
the  group  that  mass  in  Galen's  vein.  It  came  from  the 
calcarine  fissure  and  adjacent  region,  all  the  way  forward 
to  the  branches  of  the  callosal  vein  just  described. 

CCELIAN    VEINS.     (Plate  I.,  Fig.  2.) 

On  cutting  fully  through  the  callosum  and  separating 
the  hemispheres  the  two  ccelian  veins  (one  in  each  lateral 
ventricle)  were  seen  to  take  a  lyre-shaped  course,  uniting 
beneath  the  splenium  to  form  the  common  vein  of  Galen. 

This  latter  vessel  curved  upward  around  the  splenium 
much  as  in  the  human  subject,  only  that  it  made  a  less 
acute  angle  with  the  sinus  rectus.  In  fact,  it  entered  this 
at  barely  a  right  angle,  instead  of  doubling  on  itself  at  this 
point  as  in  man.  Just  before  emptying  it  received  on  its 
upper  or  concave  aspect  the  supra-callosal  vein  already  de- 
scribed. 

The  general  arrangement  of  the  ventricular  veins,  even 
to  the  choroidal  (double  on  the  right,  at  least),  was  practi- 
cally identical  with  that  in  man.  The  extra-ventricular 
efferents  of  Galen's  vein  represent  a  slightly  more  extensive 
area  than  in  the  human. 

VEINS    OF    THE    BASE. 

On  each  side  there  was  in  both  specimens  a  large  vena 
basilaris.  This  took  the  usual  branches  on  the  base,  in- 
cluding all  those  deep  in  the  Sylvian  fissure.  Here,  as 
commonly  in  the  human,  there  was  a  wide  deviation  from 
the  descriptions  of  our  anatomies.  The  superficial  veins  of 
the  middle  and  lower  Sylvian  region  took  a  course  quite 
distinct  from  those  at  the  bottom  of  the  fissure.  This 
deep  Sylvian  to  the  basilar  receives,  of  course,  the  small  pre- 


CENTRAL  NERVOUS   SYSTEM.  29 

perforating  veinules  ;  but  it  also  extends  out  beyond  them, 
and  at  least  connects  with,  if  it  does  not  more  fully  drain, 
those  of  the  insula.  Such  a  matter  is  of  some  import,  for, 
as  shown  elsewhere,  the  veins  assume  new  relations  much 
more  slowly  than  do  the  arteries. 

Each  basilar  emptied  centrally,  the  left  into  the  ccelian 
vein  (velar  or  intima)  near  its  termination,  the  right  directly 
into  Galen's  vein.  In  man  this  discharge  of  the  basilar 
per  Galen's  vein  holds  for  only  about  one-half  the  cases. 

As  to  the  floccular  and  cerebellar  veins,  it  can  only  be 
said  that  in  one  specimen  there  was  on  the  right  a  large 
vessel  coming  up  along  the  crus  cerebri,  directly  from  the 
floccular  region,  to  join  the  basilar  vein.  This  took. up 
en  route  a  vein  from  the  fissura  hippocampi. 

Taken  as  a  whole,  the  arrangement  of  the  brain -veins  in 
the  monkey,  while  corresponding  closely  to  that  in  the 
human,  is  simpler,  shows  a  more  uniform  symmetry,  and  has 
a  more  favorable  discharge.  There  is  much  less  counter- 
delivery  to  the  current  on  entering  the  sinuses,  in  particular 
as  regards  Galen's  and  the  post-supra-cerebral  veins.  The 
anastomoses,  though  less  marked,  are  doubtless  propor- 
tionately large. 

In  several  places,  notably  over  the  occipital  region 
towards  the  long  sinus,  and  also  in  the  lateral  ventricles,  it 
was  not  unusual  to  find  the  veins  directly  cross  each  other. 
In  places  one  vein  even  sent  a  complete  loop  directly 
under  another. 


IV. 


ON     THE    REMAINS    OF    A    FORAMEN     SPHENO-TEMPORALE 

IN    MAN. 

In  the  last  paper  this  name  (spheno-temporal  foramen  or 
canal)  was  given  to  a  passage  through  the  great  wing  of 
the  sphenoid,  of  some  importance  to  the  venous  circulation 
in  the  brain  of  the  monkey.  It  is  natural  to  inquire  whether 
something  of  the  kind  does  not  occur  occasionally  in  man 
also.     And  examination  serves  to  confirm  this  supposition. 

In  a  second  monkey's  skull  this  vein  from  the  temporal 
lobe  was  found  to  run,  on  each  side,  a  slightly  greater  dis- 
tance along  or  under  the  border  of  the  spheno-orbital  crest 
(boundary  between  middle  and  anterior  cranial  fossae)  be- 
fore passing  out  through  the  skull-wall.  But  its  course 
and  destination  were  essentially  as  in  the  first. 

In  both  man  and  the  monkey  this  foramen  or  canal 
passes  out  through  the  great  wing  of  the  sphenoid.  Ex- 
teriorly it  is  analogous  to  one  of  the  favorite  exits  for  the 
vena  diploetica  temporalis  anterior,  which  vessel  may  empty 
into  the  vena  temporalis  profunda  (at  the  bottom  of  the  ex- 
ternal temporal  fossa)  or  may  discharge  into  the  sinus  alae 
parvae  (within  the  cranium). 

Without  doubt  in  the  monkey  this  vein  from  the  tem- 
poral lobe,  while  traversing  the  diploe,  does  connect  with 
its  vessels. 

The  fact  that  this  opening  lets  out  a  diploic  vein  may 
have  obscured  the  other  fact  that  it  also  serves  for  the 
30 


CENTRAL  NERVOUS   SYSTEM.  3 1 

transit  of  an  emissary.  This  transmitted  vein  offers  a  direct 
communication,  more  or  less  frequent  in  man,  between  the 
deep  temporal  veins  and  those  of  the  brain  proper. 

An  examination  of  thirty  human  skulls  (several  of  them 
Indian  and  prehistoric  *)  from  the  collection  of  the  Long 
Island  College  Hospital  was  made  to  determine  the  con- 
stancy of  such  exits  on  the  outer  or  temporal  surface  of 
the  great  wing  of  the  sphenoid.  Of  these  thirty  there  were 
four  with  no  openings  on  either  side,  six  with  none  on  the 
right,  and  one  with  none  on  the  left.  Hence  of  the  sixty 
sphenoid  alae  forty-five  (or  seventy-five  per  cent.)  presented 
such  apertures.  Even  in  the  negative  cases  some  had  sub- 
stitute openings  outward,  just  under  the  base  of  the  wing, 
or  apparently  by  orifices  in  the  neighboring  bones. 

These  openings  are  usually  very  small  (the  largest  was 
barely  two  millimetres  in  diameter),  and  are  often  two  or 
more  in  number  on  each  wing.  Their  most  typical  location 
is  about  the  middle  of  this  exterior  sphenoid  surface.  In 
fifteen  (or  one-third)  it  is  specially  noted  that  they  were 
about  this  site  ;  in  nine  they  were  distinctly  high  or  low 
on  the  surface  ;  and  in  twenty-one  this  point  was  not  noted 
(not  classifiable). 

It  is  probable,  as  indicated,  that  these  openings,  when 
present,  regularly  connect  with  intracranial  vessels.  In 
only  two  was  so  straight  a  passage  found  that  a  fine  probe 
could  be  dropped  through  into  the  cranial  cavity.  In 
seven  others,  water  injected  at  the  outer  orifice  flowed 
through  into  the  inside.  In  most  of  the  others  the  opening 
was  too  small  for  practical  injection.  In  all  the  certain  cases 
the  inner  orifice  was  in  the  anterior  wall  of  the  sphenoid 

*  In  these  the  positive  results  were  slightly  under  the  general  average. 


32  CENTRAL   NERVOUS   SYSTEM. 

fossa,  under  the  spheno-orbital  crest,  and  hence,  in  life, 
opposite  the  tip  of  the  temporal  lobe.  At  this  point  or 
region  on  the  inner  surface  are  commonly  a  number  of 
small  openings  in  the  bone,  giving  it  a  perforate  appear- 
ance. Here  is  also  a  point  where,  according  to  many 
anatomists,  the  medidural  and  diploic  veins  connect  quite 
constantly. 

Hence  we  have  here  a  minor  venous  confluence, — the 
pretemporal  diploic  vein,  the  medidural  vein,  and  the 
sphenoidal  sinus  (in  the  monkey  the  vein  from  the  tem- 
poral lobe)  connecting  more  or  less  freely. 

The  thickness  and  cancellated  structure  of  the  bone  at 
the  junction  of  the  sphenoid  wing  and  the  angle  of  the 
frontal  bone  serve  frequently  to  obscure  and  scatter  the 
directness  of  this  communication  in  the  human  skull. 

In  man  this  passage  must  connect  through  the  sphe- 
noidal with  the  cavernous  sinus  ;  or  instead  it  may  run 
to  the  occasionally  present  inferior  sphenoidal  sinus  of  Bell 
(present,  according  to  Knott,  in  about  twenty-five  per  cent, 
of  all  cases). 

Not  rarely  in  man  a  medicerebral  vein  (v.  "Veins  of 
Brain,"  p.  38)  empties  into  the  sphenoidal  sinus,  and  is  then 
analogous  to  the  usual  course  of  the  vein  in  the  monkey. 

This  passage  can  best  be  classed  as  an  emissarium  of  the 
type  inconstant,  though  common  in  man.  It  should  be 
added  to  such  lists  as  that  given  by  the  writer  in  Buck's 
"Reference  Hand-Book"  (vol.  viii.  p.  243).  In  the  human 
it  is  of  theoretical  rather  than  practical  interest,  though  it 
may  serve  as  a  minor  substitute  outlet  in  thrombosis  of  the 
deeper  sinuses,  or,  on  rare  occasions,  be  of  some  impor- 
tance pathologically  in  transmitting  morbid  processes  from 
without.  J 


V. 


THE  ARRANGEMENT  OF  THE  SUPRA-CEREBRAL  VEINS  IN 
MAN,  AS  BEARING  ON  THE  THEORY  OF  A  DEVELOP- 
MENTAL  ROTATION   OF  THE   BRAIN.* 

Although  this  theory  of  Alex.  Hill  was  first  proposed 
in  1885,  and  further  elaborated  in  1887  {Brain,  Part  36), 
the  short  sketch  appended  to  his  translation  of  Obersteiner 
(1890)  will  doubtless  serve  to  gain  for  it  much  more  general 
attention.  As  it  has  not,  however,  been  worked  out  much 
beyond  the  stage  of  an  attractive  suggestion,  it  may  be 
in  order  to  point  out  any  other  facts  bearing  thereon.  In 
the  first  place,  his  view  is  hardly  described  in  sufficient 
detail  to  make  it  in  all  respects  clear,  and  at  best  should 
not  be  taken  too  literally  as  regards  minor  points.  He 
compares  the  form  of  the  perfected  mammalian  brain, 
meaning,  of  course,  each  hemicerebrum,  to  that  of  a  ram's 
horn  or  of  a  loop  or  kink.  It  might  quite  as  well  be 
likened  to  one  turn  of  a  spiral.  To  comprehend  this  more 
clearly,  as  applied  to  the  brain,  we  should  remember  that 
a  structure  may  simply  enlarge  without  otherwise  changing 
its  internal  or  external  relations,  or  it  may,  without  change 
in  volume,  undergo  any  variation  in  shape  ;  or,  finally,  as 
is  the  view  in  the  present  case,  it  may  both  enlarge  in  vol- 

*  Read  before  the  Association  of  American  Anatomists  at  the  Washington 
Congress,  September  24,  1891,  and  reprinted  from  the  Journal  of  Nervous 
and  Mental  Disease,  November,  1891. 

3  33 


34  CENTRAL  NERVOUS   SYSTEM. 

ume  and  double  or  become  twisted  on  itself.  That  the 
human  cerebrum,  as  compared  with  that  of  lower  orders, 
has  expanded  in  certain  parts  and  directions  is,  of  course, 
an  old  observation.  But,  besides  this,  the  claim  is  now 
made  that  the  primarily  straight  brain  has  in  its  growth 
become  reflected  and  curved  on  itself  in  such  a  way  that 
it  may  be  likened  in  general  outline  to  a  ram's  horn,  the 
apex  of  the  temporal  lobe  representing  the  tip  of  the 
horn. 

For  the  present  purpose  it  is  not  necessary  to  enter  into 
the  particulars  of  the  theory  or  the  arguments  advanced^ 
further  than  to  say  that  he  makes  no  use  of  local  circulatory 
peculiarities  in  support  of  his  position. 

For  instance,  the  distribution  of  the  precerebral  artery 
is  very  suggestive  of  a  reflected  field.  This  is  noticeable 
in  a  general  way  in  Duret's  plates  {Arch,  de  Physiology 
Paris,  1874),  but  is  more  strikingly  apparent  in  my  later  ones 
(Wood's  "Reference  Hand-Book,"  vol.  viii.,  New  York, 
1889).  As  these  last  were  simply  drawn  to  fact  without 
thought  of  theory,  they  offer  the  better  evidence.  It  is 
also  noticeable,  in  dissecting  out  these  precerebral  branches, 
that  they  run  in  juxtaposition  to  the  parent  stem  for  a  sur- 
prising distance  before  glancing  off  to  their  respective 
fields. 

But  it  is  evident  that  the  arteries,  since  they  are  more 
under  the  influence  of  an  internal  directing  pressure,  would 
more  rapidly  conform  and  adapt  themselves  to  any  new 
position  than  would  the  veins  with  their  interior  pressure 
almost  nil.  Hence,  from  the  veins,  if  from  either,  might 
we  most  naturally  expect  evidence  relating  to  this  point ; 
and  of  the  veins,  those  that  from  this  theory  would  be 
subjected  to   the   greatest   displacement, — viz.,  the  supra- 


CENTRAL   NERVOUS   SYSTEM.  35 

cerebrals.  These  lie  along  part  of  the  greater  curvature  of 
this  supposed  spiral. 

Except  very  casually,  Hill  does  not  consider  whether,  in 
this  transformation,  any  role  is  played  by  the  enveloping 
membranes.  However,  the  pia,  being  so  abundantly  con- 
nected with  the  brain  by  innumerable  arterioles  and  veinules, 
and  also  so  involved  by  folds  in  the  fissures,  must  naturally 
be  carried  along  to  the  same  extent  as  the  apposed  cere- 
bral tissue.  The  more  external  membranes,  on  the  con- 
trary, are  but  slightly  connected  with  the  brain,  and  as  in 
any  such  twisting  of  the  brain  its  envelopes  must  naturally, 
for  their  own  part,  perform  a  purely  passive  role,  it  follows 
that  the  dura  and  skull  are  not  carried  along  in  toto,  but 
simply  conform  by  expansion  or  contraction  to  the  growth- 
demands  of  the  subjacent  brain  proper.  Hence,  at  the 
only  points,  exclusive  of  the  base,  where  there  are  any  con- 
nections between  dura  and  pia,  some  results  of  the  tension 
produced  by  the  dragging  of  the  one  on  the  other  would 
be  probable.  The  main  connections  of  this  kind  are  again 
the  supra-cerebral  veins. 

On  this  point  part  of  the  evidence  to  be  quoted  was 
published  a  full  year  before  the  first  appearance  of  Hill's 
proposition,  and  hence  may  safely  be  considered  free  from 
any  bias  of  previous  knowledge.  ("Veins  of  the  Brain," 
Brooklyn,  1884,  pp.  14,  15):  "  It  was  long  since  observed 
that  the  more  anterior  supra-cerebrals  take  a  course  very 
nearly  at  right  angles  to  the  sinus,  and  that  the  posterior 
ones  take  more  and  more  an  oblique  course,  to  such  an 
extent  that  the  most  posterior  ones  must  run  forward  a 
distance  of  three  to  four  centimetres.  Here  they  termi- 
nate in  the  sinus,  with  a  very  acute  angle,  against  the 
blood-current.     The  vein  coming  from  the  convexity  makes 


36  CENTRAL   NERVOUS   SYSTEM. 

at  the  edge  of  the  longitudinal  fissure,  or  somewhat  farther 
out  and  back  in  the  pia,  the  necessary  angle  in  order  to 
approach  the  sinus  as  described.  It  then  runs  a  short  dis- 
tance fonvard  before  leaving  the  pia.  .  .  .  The  anterior 
supra-cerebrals,  more  often  than  the  posterior  ones,  spring 
over  from  the  pia  to  the  dura  at  some  distance  (one  to 
three  or  four  centimetres)  laterally  from  the  sinus.* 

"  The  posterior  ones  reach  the  side  of  the  sinus,  and  the 
most  posterior  ones  even  curve  fonvard  before  leaving  the 
pia,  but  the  distance  from  this  point  to  that  where  they 
empty  into  the  sinus  is  at  least  equal  to  that  in  the  varying 
anterior  ones."  Page  15  :  "The  anterior  (supra-cerebral) 
veins  empty  above  or  at  the  side  of  the  sinus,  compara- 
tively unhindered,  as  though  they  came  straight  from  the 
dura.  The  veins  farther  back,  however,  discharge  more 
and  more  at  the  side  and  bottom  of  the  sinus,  and  those 
farthest  back  empty  almost  without  exception  at  the  bot- 
tom. Many  of  the  latter,  indeed,  must  take  an  upward 
course  through  the  falx  cerebri  and  travel  a  considerable 
distance  before  they  reach  the  lowest  part  of  the  sinus." 
On  this  last  matter  Trolard  had  previously  made  a  similar 
observation.  The  above  quotations  sufficiently  indicate  the 
facts  which,  it  is  believed,  have  some  relation  to  the  rota- 
tion theory. 

Page  54:  "Development.  If  one  bears  in  mind  that 
the  brain  in  its  growth  doubles,  so  to  speak,  over  backward 
and  elongates  somewhat,  it  is  easy  to  see  that  from  this  .  .  . 
the  brain  would  carry  the  pia,  with  its  veins,  backward, — 
the  posterior  ones  a  considerable  distance,  the  anterior  ones 

*  This  further  progressive  distinction  between  the  anterior  and  the  posterior 
supra-cerebrals  has  since  been  again  and  more  fully  studied  by  Mittenzweig, 


CENTRAL   NERVOUS   SYSTEM.  37 

little  or  none  at  all."  (Foot-note.)  "This  can  be  prettily- 
illustrated  with  a  column  of  soft  potter's  clay.  A  stout 
cord  runs  straight  along  one  side  from  end  to  end,  repre- 
senting the  sinus  longitudinalis  ;  small  cross-strings  firmly 
fastened  to  the  large  one  at  equal  distances,  a  little  pressed 
into  the  clay,  but  with  their  ends  free,  represent  the  supra- 
cerebrals.  If  now  we  fix  one  end  of  the  column  and  cord, 
and  then  bend  the  other  end  of  the  column  in  a  direction 
away  from  the  cord,  the  latter  will  be  seen  to  no  longer 
reach  the  whole  length  of  the  now  convex  side  ;  while  of 
the  cross-strings,  the  first  are  about  as  before, — rectangular 
to  the  sinus  ;  those  farther  back  have  been  so  pulled  for- 
ward and  down  that  they  can  be  followed  some  distance 
beside  the  main  cord  before  they  pass  out  around  the 
column.  This  corresponds  closely  to  what  seems  to  have 
occurred  in  man." 

Page  55 :  "The  appearance  on  one  small  fcetal  brain 
tended  to  substantiate  this, — i.e.,  the  posterior  veins  did 
not  stand  so  oblique  to  the  sinus  as  in  the  brains  of  adults." 
This  is  very  conclusively  shown  by  the  illustrations  in  the 
more  recent  work  of  E.  Hedon  ("  Etude  Anatomique  sur  la 
Circulation  Veineuse  de  l'Encephale,"  Paris,  1888).  Plate 
V.,  Fig,  1,  from  a  human  foetus  of  three  and  a  half  months, 
shows  no  indication  of  this  angular  attitude  of  the  posterior 
supra-cerebral  veins.  Plate  V.,  Fig.  2,  from  a  foetus  of  six 
and  a  half  or  seven  months,  gives  some  evidence  of  this  ar- 
rangement, whilst  in  Plate  VI. ,  Fig.  E,  the  usual  position 
of  these  veins  in  the  human  adult  is  outlined  and  can  be 
compared  with  the  immature  forms. 

If  it  were  possible  to  determine  the  proper  size  of  col- 
umn, calculations  or  experiments  might  be  made  with  it 
and  the  results  compared  with  measurements  from  a  num- 


y 


38  CENTRAL  NERVOUS   SYSTEM. 

ber  of  adult  human  brains  in  situ,  with  a  view  to  determine 
mathematically  how  far  the  argument  from  the  veins  bears 
out  the  theory. 

Further,  it  is  probable  that  the  closing  up  in  fcetal,  or 
at  latest  during  infantile,  life  of  the  prolongation  of  the 
longitudinal  sinus  through  the  foramen  caecum  may  be  ex- 
plained by  the  same  retracting  action  of  the  supra-cerebrals 
at  their  junction  with  the  said  sinus,  especially  as  the  maxi- 
mum tension,  so  far  as  the  sinus  line  is  concerned,  would 
be  exerted  at  this  point. 

Although  the  evidence  from  the  vascular  arrangements 
as  here  cited  only  applies  to  a  portion  of  the  cerebrum,  it 
at  least  so  far  corroborates  the  rotatory  or  spiral  theory,  or 
adds  interest  to  it  as  a  working  theory. 


VI. 


ON  THE  EXPERIMENTAL  DETERMINATION  OF  THE 
METHOD  OF  DEVELOPMENT  OF  SYMMETRICAL  BRAIN- 
HEMORRHAGES. 

In  a  later  chapter,  in  connection  with  the  subject  of  bi- 
lateral cerebral  hemorrhages,  the  following  question  arises  : 
Does  the  influence  producing  these  effusions  emanate  from 
some  common  centre,  as  in  the  pons,  or  is  the  one  focus 
primary  and  the  other  induced  in  consequence  ?  It  is 
quite  possible  to  imagine  such  an  influence,  transmitted  by 
commissural  fibres  of  the  callosum. 

And,  first,  can  this  be  answered  by  experiment?  If  it 
be  but  an  occasional  occurrence  dependent  on  peculiar 
and  unusual  conditions,  then  we  might  not  be  able  to 
satisfy  the  requirements.  Otherwise  a  general  principle  is 
involved,  and  it  ought  to  be  possible  to  settle  this  experi- 
mentally. 

Direct  observation  of  any  place  on  the  brain,  corre- 
sponding to  some  translateral  point  stimulated,  must  be 
futile.  The  effects  of  the  necessary  exposure  to  air,  of  the 
anaesthetic  employed  (stupefying  consciousness  and  hence 
cortical  functions),  or  if  no  analgesic  be  employed,  then  the 
altered  cortical  innervation  due  to  fright  and  pain  must  rob 
any  such  attempt  of  all  claims  to  exactness.  If,  perchance, 
it  should  succeed,  well  and  good,  but  failure  would  be  in- 
decisive. 

39 


40  CENTRAL   NERVOUS   SYSTEM. 

Another  and  more  promising  plan  is  to  produce,  artifi- 
cially, a  focus,  with  as  little  other  injury  as  possible.  Then 
let  the  animal  come  fully  out  from  the  influence  of  any 
anaesthetic  used,  and  continue  under  as  normal  conditions 
as  possible  for  any  desired  period.  Finally,  examine  the 
corresponding  parts  on  the  non-operated  side  for  any  signs 
of  change. 

In  pursuance  of  this  plan  the  following  experiment  was 
performed.  As  only  one  was  done  on  the  monkey  and 
one  on  the  dog,  any  conclusions  drawn  from  them  are 
subject  to  revisal. 

A  healthy,  vigorous  Mexican  monkey  was  operated  as 
follows  :  Chloroform  anaesthesia.  A  short  incision  was 
made  over  the  right  parietal  region,  and  a  fine  hole  bored 
through  the  skull, — scant  two  centimetres  from  the  median 
line.  Then  a  sharp,  flat-pointed  needle  was  inserted  verti- 
cally a  limited  distance  into  the  hemisphere,  and  the  tip 
twirled  around  eccentrically  for  the  purpose  of  tearing  up 
tissue  and  making  a  hemorrhagic  focus  in  the  middle  of 
the  centrum  semiovale.  On  coming  out  of  the  anaesthetic 
the  animal  was  for  a  time  hemiplegic  on  the  left,  but  he 
presently  recovered  fully.  At  least  he  appeared  to  have 
good  use  of  all  extremities,  grabbed  with  both  hands,  and 
was  active  as  usual. 

Two  hours  were  allowed  for  the  development  of  any 
translateral  changes,  when  he  was  given  a  lethal  amount  of 
chloroform. 

The  point  where  the  needle  entered  the  cortex  was  just 
in  front  (two  to  three  millimetres)  of  the  middle  of  the 
central  fissure.  The  line  of  puncture  could  be  followed 
down  almost  to  the  ventricle.  The  main  focus  was  in  the 
albalis  immediately  above  the  roof  of  the  coele.     A  little 


CENTRAL  NERVOUS   SYSTEM.  4 1 

leaking  had  occurred  into  the  ventricle  itself.  The  whole 
volume  of  effusion  and  torn-up  tissue,  however,  was  only 
about  the  size  of  a  large  pea,  and  not  as  ample  as  desired. 

Section  and  examination  of  corresponding  parts  on  the 
left  failed  to  show  any  hemorrhage  or  definite  change.  A 
couple  of  small  vessels  in  the  vicinity  were  possibly  a  little 
fuller  than  in  the  neighboring  parts  ;  but,  as  a  whole,  the 
result  must  be  classed  as  negative. 

Whether  a  larger  focus,  free  of  all  leaking,  and  a  longer 
interval  between  its  production  and  the  final  examination, 
would  give  any  positive  find  must  be  left  undecided  for  the 
present. 

Another  experiment — on  the  dog — was  similar  in  all 
respects,  including  time  allowed,  and  absolutely  negative  in 
result. 

In  the  case  of  the  lower  animals,  it  is  open  to  question 
whether  their  cranial  vaso-motor  arrangements  correspond 
sufficiently  to  those  in  man  to  make  any  experiment  of  this 
kind  worth  considering.  Even  in  the  monkey  the  work 
will  only  be  decisive  when  positive  results  of  some  kind 
are  obtained.  So  long  as  they  are  merely  negative  the 
possibility  remains  that  there  is  a  finer  differentiation  of 
these  functions  in  man,  and  that  it  cannot  be  solved  by 
animal  experimentation,  but  by  clinical  inference. 


VII. 


A  CASE  OF   INTERNAL   HYDROCEPHALUS,  DUE   TO  DISEASE 
(THROMBOTIC)  IN  THE  WALL  OF  THE  STRAIGHT  SINUS.* 

The  causes  of  internal  hydrocephalus,  exclusive  of  the 
forms  due  to  intra-ventricular  inflammation  and  compres- 
sion of  the  venous  discharge  by  tumors,  are  little  known. 
A  case  which  would  ordinarily  be  called  idiopathic,  but  in 
which  a  sufficient  cause  was  found,  is  therefore  worth 
recording.  It  occurred  in  a  six-year-old  girl  of  German 
parentage.  The  first  symptoms  of  the  trouble  began  three 
months  previously :  these  it  is  only  necessary  to  state 
briefly.  She  had  been  apparently  well  until  attacked  by 
vomiting.  This  was  followed  by  convulsive  attacks,  and 
later  by  a  variety  of  indefinite  symptoms  ;  opisthotonus  in 
the  convulsive  seizures,  pain  across  the  forehead  or  in  one 
or  the  other  ear,  general  weakness,  etc.  No  paralysis,  no 
trouble  with  vision,  intelligence  clear  to  the  last. 

She  died  under  the  charge  of  Dr.  H.  P.  Bender,  with 
whom  I  made  the  autopsy,  and  to  whom  I  am  indebted 
for  the  above  notes. 

The  skull  was  thick  and  firm.  Brain  surface  and  envel- 
opes healthy  except  as  to  the  sinuses.  No  trace  of  menin- 
gitis on  either  base  or  convexity.  On  removing  the  brain, 
clear  fluid  broke  through  the  posterior  perforated  space. 

*  Reprinted  from  the  Journal  of  Nervous  and  Mental  Disease,  April,  1887. 
42 


CENTRAL   NERVOUS   SYSTEM.  43 

The  whole  amount  of  fluid  was  estimated  to  have  been  five 
to  six  ounces.  The  superficial  gyri  were  but  very  mod- 
erately flattened.  Examination  of  the  ventricles  showed 
the  velum  interpositum  firm  and  rather  thick.  No  adhe- 
sion or  other  sign  of  inflammation  in  the  ventricles.  Both 
lateral  chambers,  and  the  third  and  fourth  ventricles  with 
the  connecting  iter,  were  dilated.  The  only  noticeable 
alteration  in  their  walls  was  the  dilatation  of  the  veins, 
especially  in  their  finer  branches.  This  was  apparent  on 
the  ventricular  roof  as  well  as  floor  (most  of  the  roof-veins 
discharge  through  the  vena  Galeni).  The  two  venae  cere- 
brae  internae  were  very  broad  and  contained  liquid  blood. 
No  cause  for  the  trouble  then  was  discovered  in  the  dis- 
tended cavities.  On  examining  the  sinus  rectus,  a  dark 
thickened  spot  immediately  attracted  attention.  This  was 
about  half  an  inch  from  the  anterior  end.  Starting  from 
the  torcular  a  director  readily  passed  up  the  sinus  until  this 
point  was  reached,  where  an  obstruction  was  met.  On 
slitting  up  the  sinus,  it  was  found  that  opposite  the  thick- 
ening an  oblique  thin  membranous  septum  had  retarded 
the  sound.  After  opening,  it  was  not  possible  to  say 
whether  the  membrane  had  completely  closed  the  nar- 
rowed sinus,  the  sound  having  made  an  opening,  or  whether 
a  fine  slit  through  it  had  existed.  Immediately  adjoining 
this  were  several  fine  fibres  crossing  from  wall  to  wall,  but 
not  like  the  bands  so  often  seen  in  the  various  sinuses. 
The  above-mentioned  thickening  in  the  sinus  wall  affected 
each  side  and  was  in  the  substance  of  the  wall  itself.  On 
cutting  through  either  side,  a  layer  of  reddish-gray  organ- 
ized material  was  found  just  in  the  position  of  the  para- 
sinual  spaces  which  occur,  in  adults  at  least,  even  along 
the  straight  sinus.     This  deposit  extended  about  one-third 


44  CENTRAL   NERVOUS   SYSTEM. 

of  an  inch,  the  remainder  of  the  sinus  being  free.  The 
longitudinal  sinus  showed  a  somewhat  similar  though  less 
advanced  condition.  Its  main  channel  was  everywhere 
free,  but  the  sini  subalterni  shone  through  full  and  black 
and  to  the  feel  presented  firm  cords.  On  opening  these, 
a  dark  fibrinous  material,  partly  organized,  was  found  firmly 
attached  to  the  surroundings.  Here,  evidently,  a  process 
had  been  going  on  quite  similar  to  that  beside  the  straight 
sinus,  but  of  a  more  recent  date.  Moreover,  lying  below 
the  vessel's  channel  these  thromboses  ■  did  not  materially 
contract  it. 

The  apex  of  the  right  lung  was  adherent  and  very  hyper- 
aemic,  though  not  presenting  any  discoverable  tubercles. 

We  know  from  many  cases  of  cerebellar  tumor  that 
compression  of  the  venous  discharge  from  the  ventricles 
may  cause  internal  hydrocephalus.  In  this  case  the  ob- 
struction developed  in  the  main  efferent  vessel  itself,  and 
hence  was  not  quite  parallel,  since  certain  anastomoses 
may  have  remained  free.  As  I  have  elsewhere  shown 
("Veins  of  the  Brain,"  1884),  the  ventricular  veins  are 
terminal  vessels,  their  only  connection  with  other  veins — 
except  by  the  sinus  rectus — being  in  their  posterior  portion 
just  before  uniting.  Here  certain  basilar  veins,  usually 
discharging  through  the  vena  Galeni,  communicate  in  a 
roundabout  way  with  other  cerebral  veins.  This  limited 
anastomosis  was  doubtless  but  slightly  interfered  with, 
except  secondarily  by  the  increased  pressure  from  the 
accumulating  fluid. 

No  history  of  syphilitic  taint  or  other  cause  for  the 
peculiar  thrombotic  condition  could  be  found. 


VIII. 

A  CASE  OF  INTERNAL  HYDROCEPHALUS  FROM  COMPRES- 
SION OF  THE  VENA  GALENI  BY  A  TUBERCULAR  EN- 
LARGEMENT OF  THE   CONARIUM    (PINEAL  GLAND). 

Girl  of  four  and  a  half  years.  German  parentage. 
Never  a  vigorous  child,  though  of  good  size  for  her  age. 
The  present  trouble  was  of  about  three  weeks'  duration, 
running  under  the  clinical  appearance  of  a  meningitis,  and 
ending  in  coma.  There  had  been  no  pupillary  symptoms 
(normal  reactions)  and  no  paralysis. 

Autopsy  through  the  courtesy  of  the  attending  physician, 
Dr.  H.  P.  Bender,  March  6,  1891  (thirty-six  hours  p.m.)  ; 
to  him  are  also  due  the  clinical  notes  already  given. 

Dura  much  injected,  apparently  venous.  Small  Pacchio- 
nian granulations  on  either  side  of  the  longitudinal  sinus, 
along  the  line  of  the  incoming  cerebral  veins.  No  subdural 
adhesions.  No  old  clots  in  falciform  or  lateral  sinuses. 
The  brain  appeared  large  ;  gyres  not  noticeably  flattened  ; 
general  injection  of  cortex. 

On  lifting  the  brain  from  the  posterior  fossa  a  consider- 
able quantity  of  clear  fluid  suddenly  appeared, — not,  how- 
ever, more  than  one  or  two  ounces.  This  was  thought  to 
have  come  from  the  paracoeles. 

No  purulent  material  anywhere  on  the  surface.  A  slight 
opacity  of  the  arachnoid,  where  stretched  out  as  over  the 
Sylvian  fossae  or  at  the  base,  may  have  been  of  post-mortem 

45 


46  CENTRAL   NERVOUS   SYSTEM. 

origin.      Possibly  a  minute  tubercle  beside  the  basilar  ar- 
tery. 

The  paracceles  (lateral  ventricles)  appeared  to  have  been 
dilated,  and  still  contained  an  ounce  or  so  of  fluid  ;  the 
parietal  veins  of  these  cceles  were  well  filled  with  blood. 
Epiccele  normal  in  appearance. 

The  main  alteration,  in  addition  to  the  hydrocephalus, 
was  an  enlargement  of  the  pineal  gland.  This  was  the  size 
of  a  small  hazel-nut.  The  little  tumor  corresponded  to 
the  otherwise  absent  conarium. 

The  small  mass  was  directly  adherent  to  the  vena  Galeni, 
but  rested  in  a  bed  of  yellowish  lymph-material  directly 
pressing  from  above  upon  the  cerebellum  (supra-vermis  or 
central  lobule).  This  was  in  position  to  compress  Galen's 
vein,  and  perhaps,  also,  any  lymph-passages  from  the  para- 
cceles. To  this  mechanical  action  the  moderate  hydro- 
cephalus was  doubtless  due.  So  far  as  the  cursory  exami- 
nation could  establish,  it  is  quite  possible  that  some  more 
general  distribution  of  tubercles  in  the  pia  did  exist,  and 
the  clinical  history,  with  the  fatal  termination,  rather  indi- 
cated the  same. 

According  to  Henoch  ("Diseases  of  Children,"'  New 
York,  1882),  "Experience  teaches  that  tubercles  situated 
in  the  middle  lobe  of  the  cerebellum,  or  between  it  and 
the  tentorium,  are  especially  apt  to  produce  effusion  into 
the  ventricles  from  pressure  upon  the  vena  magna  Galeni 
and  its  chief  branches." 

The  marked  increase  of  Pacchionian  granulations  in  cases 
of  cerebro-spinal  meningitis  was  noted  by  Frolich  in  1881 
( Wiener  Klinik). 


IX. 

A    CASE    OF   TRAUMATIC    CEPHALHYDROCELE.* 

The  comparative  rarity  of  this  trouble,  at  least  of  pub- 
lished reports,  and  some  interesting  questions  involved, 
suggest  that  the  subject  may  be  worth  considering,  even 
though  little  new  can  be  added. 

My  case  is  that  of  a  girl  of  seven  years,  seen  in  October, 
1892,  a  patient  of  Dr.  George  E.  Law.  Her  trouble  dates 
from  an  injury  when  a  year  old.  The  mother,  with  the 
child  in  her  arms,  fell  on  the  stairs,  throwing  the  girl  some- 
what violently  into  a  corner.  This  was  immediately  fol- 
lowed by  convulsions  and  by  left  hemiplegia  not  involving 
the  face.  There  was  no  previous  paralysis  or  other  abnor- 
mity. The  physician  then  in  attendance  said  that  the 
soft  cranium  had  been  dented  in.  At  first  the  head  was 
greatly  swollen,  and  for  years  a  large  lump  remained 
over  the  region  of  injury.  This,  however,  gradually  sub- 
sided, so  that  for  the  last  three  years  it  only  puffs  out  on 
crying. 

A  year  ago  last  summer  she  was  in  convulsions  all  one 
night,  and  she  had  another  seizure  October  7,  this  year. 
She  has,  however,  also  been  having  of  late  so-called  faint- 


*  Paper  read  before  the  Brooklyn  Society  for  Neurology,  November  9, 
1892.  Here  reprinted,  with  an  illustration  and  other  additions,  from  the 
Journal  of  Nervous  and  Mental  Disease,  1893,  P-  x55- 

47 


48  CENTRAL   NERVOUS   SYSTEM. 

ing  spells  two  or  three  times  a  day,  and  has  been  less  bright 
mentally  since  the  first  convulsions.  The  latter  are  severer 
on  the  left  side  ;  no  initial  symptom,  but  a  moan  ;  always  of 
late  yawning  and  tired  ;  never  complains  of  headache,  un- 
less sometimes  of  local  tenderness  on  the  head  from  crying  ; 
the  left  hemiplegia  has  very  gradually  improved,  so  that 
only  a  paresis  remains ;  shortening  of  left  extremities 
stated  ;  knee  and  radial  jerks  stronger  on  left  than  on 
right ;  left  hand  cooler  than  right.  For  years  the  left 
thumb  and  fingers  were  drawn  in  and  the  hand  was  a  little 
flexed  ;  but  even  then,  although  not  possible  when  awake, 
yet  in  sleep  the  arm  would  be  freely  put  up  over  the  head 
{i.e.,  mimic  or  so-called  automatic  actions  intact, — by  some 
classed  as  a  thalamic  function).  Walks  limpingly  on  left 
leg  ;  can  just  about  stand  alone  on  left  foot. 

Pupils  equal ;  no  distinct  hippus.  Vision  in  left  eye 
possibly  impaired,  yet  fairly  good  ;  in  right,  normal. 
Pulse,  1 08  (standing).  Sleeps  well  and  without  special 
dreaming.  She  is  a  plump,  healthy,  and  bright-looking 
child.  Cannot  read  yet,  but  can  count  some.  Has  a  lively 
interest  in  everything,  is  properly  inquisitive,  laughs,  plays, 
etc. 

There  is  a  long,  somewhat  transverse  depression  in  the 
skull,  reaching  slightly  backward  to  the  left  of  the  median 
line,  and  crossing  the  sagittal  suture  an  inch  or  so  in  front 
of  the  lambdoid.  The  main  part  runs  from  this  point 
obliquely  forward  and  somewhat  downward  over  the  upper 
parietal  region  on  the  right.  The  hair-growth  and  color  of 
skin  over  this  part  are  normal.  When  the  child  is  mentally 
excited  there  is  a  filling  up  of  the  depression  ;  that,  how- 
ever, can  be  very  easily  forced  back  by  pressure  with  the 
finger-tips.     It  also  fills  some  on  compressing  the  jugulars. 


CENTRAL   NERVOUS   SYSTEM.  49 

No  distinct  opening  can,  however,  be  felt,  though  there  is 
evidently  one  at  the  bottom  of  the  hollow.  When  she  lies 
down  the  whole  depression  fills  up,  even  a  trifle  more  than 
level,  yet  is  also  very  easily  emptied,  showing  a  pretty  free 
communication  with  the  encranium. 

Pulsation  did  not  seem  noticeable  when  the  cyst  filled 
by  lowering  the  head,  but  became  very  evident  when  in 
erect  postures  it  filled  by  any  mental  effort, — i.e.,  there  was 
decided  pulsation  only  when  the  fluid  was  driven  up  by  an 
actively  increased  arterial  supply  to  the  brain.  Perhaps 
this  is  the  explanation  of  the  fact  that  in  some  cases  pul- 
sation is  observed  and  in  others  not,  although  the  size  of 
the  communication  must  also  be  a  factor, — a  minute  open- 
ing diminishing  the  pulsatory  movement. 

We  aspirated  and  removed  about  two  drachms  of  a  clear, 
colorless  fluid  like  water,  except  for  some  minute  floating 
particles  or  shreds.  The  puncture,  through  a  firm  cyst 
wall,  did  not  appear  to  cause  any  pain,  nor  did  the  with- 
drawal of  this  small  quantity  of  fluid  have  any  percep- 
tible effect  on  the  patient.  The  cavity  immediately  refilled, 
and  even  leaked  some  through  the  oblique  puncture  while 
she  remained  reclining,  thus  showing  an  abundant  source. 
Microscopical  examination  of  the  aspirated  fluid  showed  : 
occasionally  a  leucocyte  ;  rare  irregular  flakes  and  fibres, 
sometimes  a  little  pigmented ;  otherwise  only  uncertain 
and  foreign  matters.  Subsequent  puncturing  failed  to  do 
any  great  amount  of  good. 

Though  the  total  experience  with  this  form  of  trouble  is 
limited,  it  suffices  to  indicate  that  the  cyst  in  this  case  con- 
nects with  the  lateral  ventricle,  and  that  the  fluid  is  cerebro- 
spinal. Further  and  decisive  proof  was  given  by  the 
chemical    examination.     This   was   made   by  Dr.   Bartley, 

4 


50  CENTRAL   NERVOUS   SYSTEM. 

and,  as  it  involves  recent  methods  not  (so  far  as  I  am 
aware)  ever  applied  to  one  of  these  cases,  I  have  asked 
him  to  contribute  a  brief  account  of  the  main  decisive 
tests  (v.  special  article,  p.  21). 

His  results  in  this  case  were  as  follows  : 

Specific  gravity  (by  weight),  10 10. 

No  precipitation  by  heat. 

All  proteids  precipitated  by  magnesium  sulphate. 

A  precipitation  by  cold  nitric  acid. 

No  precipitation  by  hot  nitric  acid. 

With  Fehling's  solution  doubtful. 

This  excludes  serum  albumin,  but  includes  albumose,  and 
in  general  shows  that  the  fluid  corresponds  well  to  cerebro- 
spinal, but  not  to  that  from  any  independent  cyst. 

The  differential  diagnosis  in  well-marked  cases  is  almost 
alone  from  venous  cysts  (v.  Martin,  "Venous  Blood  Tu- 
mors of  the  Cranium,"  Journal  Am.  Medical  Association, 
September  18  and  25,  and  October  2,  1886).  Hernia  cere- 
bri, encephalocele,  etc.,  are  often  congenital  and  not  readily 
reducible.  Aspiration  (and,  if  necessary,  an  examination 
of  the  fluid)  settles  the  diagnosis. 

It  has  been  noted  that  all  cases  are  in  the  young.  It  is 
not  probable  that  they  all  die  before  advancing  far  in  years, 
but  that,  as  in  Southam's  case  (though  in  Makins's  the 
opposite  was  occurring),  either  the  external  part  shrinks  up 
or  the  cranial  opening  becomes  shut  off  spontaneously  or 
by  the  natural  bone-growth,  thus  leaving  simply  an  encra- 
nial  cyst  (ventricular  diverticle),  a  course  that  the  present 
case  also  is  following.  Evidently  of  this  nature  are  many 
of  the  cases  of  late  glibly  dubbed  porencephalus  :  that 
of  Dr.  Barber  (described  at  the  same  meeting),  that  of 
Brush,  and  others.     This  makes  the  pathology  somewhat 


CENTRAL  NERVOUS   SYSTEM.  5 1 

comparable  to  that  in  cases  of  syringomyelia  starting  from 
the  central  canal. 

As  to  treatment  :  One  negative  indication  has  been 
established,  both  by  theory  and  experience.  Do  not  at- 
tempt surgical  interference.  The  cases  so  far  operated 
appear  all  to  have  ended  fatally,  except  that  of  Halley. 
Tapping  also  proves  of  little  use,  except  when  necessary 
to  relieve  pressure. 

The  literature  of  the  subject  is  not  great,  the  principal 
English  and  American  papers  being, — 

R.  Clement  Lucas  :  Two  cases,  each  illustrated.  Guy 's 
Hospital  Reports,  1876,  1878,  and  1880-81. 

Connor:  Am.  Journal  of  Med.  Sciences,  July,  1884.  He 
collected  twenty-two  cases,  including  two  of  his  own. 

Southam  :  Description  accompanied  by  drawing  of  case. 
Brit.  Med.  Journal,  May  12,  1888,  pp.  1004,  1005. 

Makins  :  Trans.  Clin.  Society,  London,  1887,  pp.  203, 
204. 

Halley,  of  Kansas  City:  Jrnl.  Am.  Med.  Assoc,  1893, 
ii.  86,  87.  One  of  his  cases  (Bertha  Thalin)  was  clearly 
of  this  type,  and  eventually  recovered  from  operation, — 
probably  the  first  to  do  so. 

My  recollection  also  includes  a  misplaced  society  report, 
probably  American. 

A  few  considerations  may  be  added  as  to  the  way  such 
cysts  (or  diverticles  of  the  ventricle)  originate.  It  is  at 
least  improbable  that  a  simple  rupture  of  the  ventricular 
wall  (ependyma)  could  alone  lead  to  this  result,  although  it 
doubtless  occurs  as  a  preliminary  factor.  The  case  is  prac- 
tically a  special  form  of  internal  hydrocephalus.  There  is 
no  evidence  to  show  that  this  is  here  kept  up  by  any  con- 
tinuous inflammation  of  the  secreting  choroidal  villi.     There 


52  CENTRAL   NERVOUS   SYSTEM. 

seem  to  be  two  possible  ways  left,  involving  an  interference 
with  either  :  (a)  the  ventricular  venous  efferents,  or  (b)  the 
normal  discharge  of  the  ventricular  fluid.  In  at  least  many 
of  these  cephalhydrocele  cases  the  connection  with  the 
ventricle  is  at  a  point  in  the  region  of  what  may  be 
termed  the  ventricular  outlet,  or  neck  of  the  ccele  (in  ours, 
evidently  the  roof  over  this  part).  A  slight  dragging,  dis- 
placement, cicatricial  constriction,  or  even  fibrinous  plug- 
ging at  this  point,  might  suffice.  Until  some  more  exact 
explanation  can  be  given,  I  think  we  may  contentedly 
conclude  that  obstruction  at  this  outlet  is  the  cause.  The 
same  holds  also  for  quite  a  proportion  of  the  miscellaneous 
cases  of  hydrocephalus.  Surgical  measures,  by  any  plan 
so  far  proposed,  must  prove  unavailing  in  all  such  cases, 
largely  by  reason  that  the  real  cause  is  not  removed,  and 
the  like  applies  to  all  attempts  at  cure  by  tapping. 

Re-examined  December  27,  1896.  Condition  continues 
essentially  as  when  first  seen.  For  a  couple  of  years  in  the 
interim  she  was  free  from  convulsions,  but  an  attack  of 
scarlet  fever  brought  them  back  again.  Since  the  few 
aspirations  in  1892,  there  has  been  no  swelling  of  the  head 
over  the  cleft ;  but  it  still  fills  up  to  the  edges  of  bone 
when  she  lies  down,  and  then  distinct  fluctuation  can  be 
made  out.  The  fissure  is  wide  and  deep  in  its  middle  part, 
with  an  especially  abrupt  frontal  border.  The  opening 
through  the  skull  can  be  pretty  certainly  detected  an  inch 
or  so  to  the  right  of  the  median  line. 

Is  not  as  forgetful  as  formerly.  Front  part  of  left  half 
of  tongue  is  much  atrophied.  Sensations  of  touch  and 
pain  are  good  over  left  hand  ;  this  part  is  small  and  some- 
what contracted  in  fingers  and  wrist,  though  more  useful 
than  before. 


CENTRAL   NERVOUS   SYSTEM.  53 

At  this  time  Mr.  Stucke  kindly  made  the  accompanying 
sketch.  (Plate  II.,  Fig.  4.)  It  is  from  direct  measure- 
ments, and  self-explanatory, — the  dot  representing  the  mid- 
point between  glabella  and  occipital  protuberance. 


X. 


LUMBAR  PUNCTURE  FOR  THE  REMOVAL  OF  CEREBRO-SPINAL 

FLUID.* 

There  are  a  variety  of  troubles  attended  by  an  increased 
intracranial  pressure,  and  this  often  reaches  such  a  degree 
that  relief  is  imperatively  demanded.  Brain-tumors,  men- 
ingitis, hydrocephalus,  and,  perhaps,  some  traumatic  con- 
ditions come  under  this  head  ;  and  the  list  might  include 
further  disorders  if  some  harmless  way  of  relieving  were 
available.  Of  course,  a  radical  cure  by  removal  of  the 
cause  is  the  true  desideratum,  but  in  this  class  of  cases 
such  permanent  relief  is  rarely  attainable.  Hence  we  turn 
to  any  measure  that  can  give  even  temporary  amelioration. 
And  this  seems  to  be  all  that  can  be  justly  claimed  for  the 
method  here  to  be  considered. 

In  a  paper  on  Hydrocephalus,  read  before  the  Tenth 
German  Medical  Congress  (April,  1891),  Quincke  described 
the  results  obtained  by  puncturing  with  a  hollow  needle 
and  allowing  the  excess  of  fluid  to  run  off.  This  he  had 
practised  in  part  by  boring  fine  holes  through  the  skull. 
But  he  also  described  and  endorsed  a  method  of  intro- 
ducing such  a  needle  in  the  lumbar  region  directly  through 
the  skin,   between  the  vertebral  arches,  and  tapping  the 

*  Read  before  the  American  Neurological  Association,  Washington,  May 
31,  1894,  and  reprinted  from  the  Journal  of  JVe?-votis  and  Mental  Disease, 
October,  1894. 
54 


CENTRAL   NERVOUS   SYSTEM.  55 

lumbar  subarachnoid  space.  As  the  point  chosen  is  be- 
low the  cord,  no  serious  injury  can  occur  ;  at  most  a  punct- 
uring of  some  nerve  or  small  vessel,  perhaps.  In  an  adult 
he  had  thus  in  an  hour  drawn  off  eighty  centimetres  of 
fluid.  He  recommended  this  plan  for  every  hydrocephalus 
with  pressure  symptoms,  especially  in  the  acute  forms, 
whether  simply  serous  or  of  tubercular  origin.  He  also 
suggested  subcutaneous  slitting  of  the  spinal  dura.  And 
this  has  been  done  by  Parkin — in  the  lower  cervical  region, 
however — as  well  as  practically  by  others  ;  yet  even  this 
more  thorough  plan  gave  but  transient  relief. 

Several  others  have  reported  experience  with  the  trocar- 
method,  Von  Ziemssen,  perhaps,  being  its  most  enthusiastic 
advocate.  My  first  trial  was  made  a  year  since.  As  the 
results  have  not  been  very  encouraging,  I  have  done  it  in 
but  few  cases.  In  one — that  of  an  old  hydrocephalus  with 
some  exacerbation — there  was  subjective  relief.  It  was 
also  done  in  two  cases  of  spinal  trouble  with  evidence  of 
compression  of  the  cord.  In  one  of  these  (traumatic  Pott's 
disease,  corroborated  by  autopsy),  it  was  with  a  view  to 
possible  relief  of  the  distressing  jactation,  but  to  no  pur- 
pose. In  the  other,  where  the  trouble  had  developed  sud- 
denly after  pleurisy,  the  puncture  was  for  diagnosis,  and  at 
least  excluded  meningeal  hemorrhage. 

One  case  may  be  worth  relating  more  in  detail.  This 
and  one  other  were  in  the  service  of  Dr.  Bogart  at  the 
M.  E.  Hospital,  and  it  was.  through  his  courtesy  that  I 
operated. 

Boy  of  eight  months,  with  gradually  increasing  hydrocephalus.  External 
strabismus  on  right.  Is  apparently  blind,  though  pupils  react.  Fontanelle 
large  and  full  and  approaching  sutures  open.  Some  tonic  contracture  of  legs 
and  arms.     As  he  had  first  developed  an  irregular  fever  and  some  vomiting, 


56  CENTRAL   NERVOUS   SYSTEM. 

it  was  a  question  about  proceeding,  but  we  decided  that  interference  was 
all  the  more  warranted.  No  anaesthetic.  The  child  alternately  slept  and 
cried  a  little  during  the  withdrawal  of  an  ounce  and  a  quarter.  The  fon- 
tanelle  gradually  sank  in  and  the  sutures  closed  up,  except  when  the  child 
cried.  It  was  noticed  that  compression  of  the  head  (manual)  increased  the 
flow. 

Extremities — contracture  not  relaxed.  The  child's  condition  was  appar- 
ently not  influenced  by  the  operation.  Temperature  as  before  puncture 
went  at  times  to  105  °.  He  gradually  grew  worse,  became  comatose,  and 
died  five  days  later.  The  fontanelle  had  not  refilled.  Autopsy  by  Dr.  Jel- 
liffe.  General  congestion  of  the  membranes,  with  whitish,  irregular  patches 
over  either  temporal  apex.  Vast  clear  hydrocephalus  of  lateral  ventricles. 
It  extended  freely  into  the  third,  and  by  a  short  dilated  aqueduct  into  the 
fourth.  This  showed  a  subarachnoid  continuation  down  spine.  On  open- 
ing over  the  lumbar  cord  much  free  clear  fluid  was  found.  No  apparent 
injury  from  the  puncture.  The  appearance  suggested  that  some  of  the 
fluid  had  escaped  through  the  opening  and  collected  in  the  extra-dural 
space. 

This  was  a  valuable  case.  At  the  time  of  puncture  there 
seemed  to  be  an  acute  increase  of  the  hydrocephalus,  per- 
haps a  developing  meningitis.  The  fact  that  pressure  on 
the  skull  accelerated  the  outflow,  that  the  fontanelle  sank 
and  remained  so,  and  that  at  the  autopsy  the  fourth  ven- 
tricle was  found  to  participate  and  the  fluid  here  to  connect 
with  that  below, — all  this  shows  that  the  tapping  as  such 
was  successful.  Thus  it  was  a  specially  favorable  case, 
because  of  the  good  evidence  that  the  pressure  of  the  effu- 
sion actually  was  reduced.  And  yet  the  intervention  did 
nothing,  either  to  prolong  life  or  relieve  symptoms.  In 
many  cases,  symptomatically  like  this,  the  effusion  does  not 
extend  into  the  fourth  ventricle  even,  and  then  there  can 
be  little  chance  of  withdrawing  fluid  from  the  cerebral  col- 
lection through  any  spinal  puncture.  The  entire  failure  to 
relieve  in  this  instance  has  deterred  me  from  performing  it 
in  subsequent  cases  of  the  kind. 


CENTRAL   NERVOUS   SYSTEM.  57 

ACCIDENT. 

In  one  case,  a  girl  of  twelve  years,  with  a  supposed  in- 
ternal hydrocephalus  from  old  meningitis,  after  only  half  a 
drachm  had  been  secured,  the  respiration  stopped.  Nar- 
cosis was  of  course  discontinued,  and,  thanks  to  the  pro- 
longed efforts  of  the  staff,  the  girl  was  resuscitated.  Pos- 
sibly a  very  slight  elevation  of  the  head,  in  the  hope  of 
increasing  the  scant  flow,  may  have  favored  this  occurrence  ; 
certainly  neither  the  puncture  nor  the  small  quantity  with- 
drawn was  thought  at  all  responsible. 

DIRECTIONS. 

Patient  in  the  recumbent  posture  on  the  left  side.  The 
knees  may  be  drawn  up  and  the  spine  flexed,  giving  a 
curve  posteriorly. 

An  anaesthetic  is  usually  advisable  in  adults  and  older 
children  where  normal  sensation  exists.  Still,  in  these 
cases  with  increased  brain-pressure  there  may  be  more 
than  the  usual  risk. 

Elevating  the  head  has  not  increased  the  outflow,  and, 
especially  if  an  anaesthetic  be  used,  is  not  without  danger. 

Strict  asepsis,  needle  sterilized,  etc. 

Usually  it  is  easier  to  go  in  between  the  third  and  fourth 
lumbar  vertebrae.  Only  once  have  I  succeeded  between 
the  fourth  and  fifth. 

A  long,  firm,  smooth  aspirating  needle  (No.  3  French, 
or  from  2^/2  to  4)  answers  well.  This  can  easily  be  con- 
nected with  a  tube  for  determining  pressure  if  desired. 
Special  needles  have  been  devised,  but  seem  unnecessary. 

Enter  a  little  to  one  side  of  the  median  line  (five  to  ten 
millimetres  laterally,  though  in  children  it  may  be  better  to 
pass  directly  between  the  spinous  processes).      As  these 


58  CENTRAL   NERVOUS   SYSTEM. 

latter  here  incline  downward,  the  tip  of  the  needle  on 
reaching  the  space  selected  may  be  tilted  up  a  little  the 
more  readily  to  enter  between. 

In  my  adult  cases  the  length  inserted,  to  the  opening  in 
the  needle,  has  varied  little  from  five  centimetres.  In 
children  of  eight  months  and  twelve  years,  respectively, 
it  was  only  two  and  a  half  centimetres.  These  two  figures 
give  about  the  range  of  variation  (Quincke  says  from  two 
to  six  centimetres). 

The  amount  to  be  drawn  off  is  clearly  indicated  in  each 
case.  It  may  be  allowed  to  run,  or  more  commonly  drip, 
until  the  flow  spontaneously  reduces  or  ceases.  This  shows 
that  the  pressure  is  relieved,  and  yet  only  within  proper 
limits.  There  seems  to  be  no  danger  of  air  entering. 
Sometimes  the  fluid  at  first  comes  out  tinged  with  blood 
collected  by  the  tube  in  transit,  but  this  then  soon  gives 
way  to  clear,  colorless  fluid.  One  case  has  been  reported 
with  turbid  fluid  from  meningeal  inflammation,  and  in  one 
evidence  of  hemorrhage  (intracranial)  was  found. 

No  special  precautions  are  necessary  on  withdrawing  the 
tube  or  in  subsequently  treating  the  puncture  (iodoform- 
collodion,  if  desired). 

It  is  proper,  of  course,  for  the  patient  to  lie  quiet  for  a 
time. 

CONCLUSIONS. 

1.  The  method  is  simple,  easily  practised,  and  rather 
attractive. 

2.  In  itself  it  is  usually  without  danger. 

3.  By  it  we  certainly  can  draw  off  cerebro-spinal  fluid. 

4.  The  quantity  in  an  adult  at  short  sittings  has  been 
from  one  to  one  and  a  half  ounces. 

5.  This,  without  doubt,  represents  the  amount  of  free 


CENTRAL  NERVOUS   SYSTEM.  59 

fluid   usually  present  in   the  lower  vertebral  canal,    even 
when  occluded  above. 

6.  In  internal  hydrocephalus  the  relief,  if  any,  is  but 
very  temporary.  In  the  common  form  due  to  tubercular 
meningitis  the  result  is  not  worth  the  trouble,  while  in  the 
closed  or  sacculated  forms  it  must  rather  do  harm  than 
good. 

7.  As  a  diagnostic  means — e.g.,  in  suspected  meningeal 
hemorrhage — it  is  valuable.  And  as  an  index  of  pressure  it 
may  also  be  worth  noting. 

8.  It  is  worth  further  trial :  (a)  as  a  passing  relief  in 
brain-tumors  not  complicated  with  hydrocephalus  ;  (b)  as 
a  substitute  for  trephining  in  progressive  dementia ;  (c)  in 
certain  spinal  troubles  ;  id)  and  possibly  as  a  means  of  ap- 
plying medication  directly  to  the  spinal  meninges. 

9.  In  conclusion,  it  may  be  said  that  while  admissible  in 
all  cases  of  brain-pressure,  there  is  nevertheless  as  yet  no 
established  indication  for  this  procedure,  except  for  diag- 
nostic purposes. 

LITERATURE. 

1.  H.  Quincke.  Ueber  Hydrocephalus.  Verkandlungen  d.  X.  Congr.  f. 
Innere  Med.,  1891. 

2.  H.  Quincke.  Die  Lumbalpunction  bei  Hydrocephalus.  Berliner  klin. 
Wochnschr.,  1891.     Nos.  38  and  39. 

3.  E.  Wynter.  Four  Cases  of  Tubercular  Meningitis  in  which  Paracentesis 
of  the  Theca  Vertebralis  was  performed  for  the  Relief  of  Fluid-Pressure. 
Lancet,  May  2,  1891. 

4.  O.  Wyss.  Zur  Therapie  des  Hydrocephalus.  Corresp.-Blatt  f.  Schweizer 
Aerzte,  1S93.     No.  8. 

5.  Parkin.  [Opened  vertebral  canal  for  relief  of  fluid-pressure  ;  case  ended 
fatally.]     Lancet,  1893,  ii. 

6.  Von  Ziemssen  and  others.     XII.  German  Med.  Congress. 

P.  S. — The  later  foreign  literature  is  too  ample  for  specification  here. 
Since  the  publication  of  the  above  paper  the  subject  has  received  consider- 
able attendon  in  this  country  also,  and  several  articles  have  appeared. 


60  CENTRAL   NERVOUS   SYSTEM. 

7.  Aug.  Caille,  N.  Y.  Med. /ml.,  ]une  15,  1895,  pp.  750,  751. 

8.  G.  W.  Jacoby,  ibid.,  1895,  ii.,  and  1896,  i. 

9.  D.  L.  Wolfstein,  Arch.  Pediatr.,  March,  1896,  pp.  180-191. 

10.  O.  G.  T.  Kiliani,  N.  Y.  Med.Jml.,  March  14,  1896. 

11.  W.  L.  Babcock,  State  Hospitals  Bulletin,  July,  1896. 

12.  A.  H.  Wentworth,   Bost.  M.  and  S.  Jrnl.,  Aug.  6  and  13,    ll 
(Also  Arch.  Pediatr.,  Aug.,  1896,  pp.  567-590.) 

13.  Caille,  Arch.  Pediatr.,  Aug.,  1896,  pp.  561-566. 

14.  C.  G.  Jennings  [case],  ibid.,  p.  591. 

15.  Wentworth,  Bost.  M.  and  S.  J.,  1897,  *•  P-  io7- 


XI. 


A  CONSIDERATION  OF  OBSTRUCTIVE  HYDROCEPHALUS 
AND  OF  THE  MECHANICAL  PRINCIPLES  UPON  WHICH 
ITS    DEVELOPMENT    DEPENDS. 

While  there  may  be  little  radically  new  to  be  said  on 
this  subject,  certain  explanations  or  theories  that  have  met 
with  but  limited  acceptance  can  now  be  placed  on  a  surer 
footing,  and  it  is  possible  to  apply  more  directly  than  has 
been  done  various  facts  of  recent  knowledge.  No  one 
seems  as  yet  to  have  undertaken  any  really  comprehensive 
description  of  the  many  points  that  go  to  make  up  the 
subject.  The  better  the  matter  is  understood,  the  more 
certain  does  it  become  that  all  cases  of  internal  hydro- 
cephalus are  of  this  class.  Such  terms  as  primary  and 
secondary  become  consequently  obsolete,  as  applied  to 
hydrocephalus.  There  is  no  such  thing  as  primary  in  any 
sense  in  which  the  term  has  here  been  used ;  all  cases  are 
secondary,  or  more  properly  sequelae. 

The  classification  into  acute  and  chronic  forms  is  an 
essentially  clinical  one,  and  from  that  point  of  view  justi- 
fiable. It,  however,  has  no  significance  in  the  mechanical 
sense,  although  a  larger  proportion  of  the  acute  cases  than 
of  the  chronic  may  prove  to  be  due  to  extra-ventricular 
blocking. 

The  common  and  convenient  division  into  congenital  and 
acquired  has,  in  part,  a  more  substantial  anatomical  basis. 

61 


62  CENTRAL   NERVOUS   SYSTEM. 

On  this  question  of  the  congenital  form  the  results  of  a 
study  of  the  spinal  absorbents,  given  in  another  article, 
have  an  important  bearing.  But  it  must  remain  for  a 
closer  examination  of  such  cases  from  this  new  point  of 
view  to  show  more  exactly  what  the  relation  is. 

CONGENITAL   HYDROCEPHALUS. 

While  it  is  not  proposed  here  to  take  up  this  class,  a 
word  may  be  said  regarding  it  in  passing.  Of  this  form 
we  have  but  a  poor  knowledge.  There  is  a  supposition 
that  it  depends  on  other  conditions  or  causes  than  the 
acquired  form.  Yet  the  same  principles  must  be  involved, 
at  least  so  far  as  the  immediate  cause  of  the  retention. 
In  the  elaborate  description  of  Hans  Virchow  ("  Ein  Fall 
von  angeborenem  Hydrocephalus  Internus,"  etc.,  Leipzig, 
1887)  there  is  evidence  that  in  his  case  the  fluid  was  not  pent 
up  in  the  ventricles,  but  had  connection  with  the  general 
subarachnoid  space.  It  was  due  to  a  chronic  lepto-menin- 
gitis  which  evidently  had  sealed  up  the  ultimate  absorbents. 

Some  other  congenital  cases  are  included  in  lists  given 

below. 

ACQUIRED    HYDROCEPHALUS. 

Various  explanations  according  to  the  case  have  been 

offered  to   account  for  the  increase  of  fluid.     The  most 

tenable  are, — 

a.  Closure  of  the  canal  from  the  ventricles,  particularly 
at  Magendie's  foramen, — retention  of  fluid. 

b.  Interference  with  the  venous  discharge,  in  particular 
of  Galen's  vein, — over-production  of  fluid. 

c.  Inflammation  or  other  irritation  of  the  choroidal  villi  * 


*  Rindfleisch  ("Pathol.  Anat.")  is  credited  as  one  of  the  first  to  insist  on 
the  role  of  lesions  of  the  choroid  plexus  in  the  production  of  ccelian  dropsy. 


CENTRAL   NERVOUS   SYSTEM.  63 

in  the  ventricles  (ependymitis,  hyperplasia  of  the  choroid 
plexus,  meningitis  serosa,  tubercular  meningitis,  etc.), — also 
increased  production. 

These  causes  of  themselves  do  not  offer  an  explanation 
of  the  retention,  and  more  careful  examination  at  autopsies 
will  somewhat  reduce  the  apparent  frequency  of  such 
cases.  Even  in  tubercular  meningitis  it  not  rarely  tran- 
spires that  there  is  ample  obstruction  from  specially 
situated  tubercular  or  inflammatory  material  to  explain  the 
accumulation. 

d.  The  stretching  form  of  Huguenin,  occurring  only  in 
the  young  (a  kind  of  passive  or  relative  retention).  This  is 
supposed  to  be  due  to  abnormally  diminished  resistance  of 
the  cranial  walls  from  malnutrition  and  imperfect  develop- 
ment. Here  rickets  and  hereditary  syphilis  play  the  chief 
role.  Or  it  is  attributed  to  the  head  strain  of  coughing 
(pertussis,  chronic  bronchitis,  etc.).  On  the  balloon-valve 
principle,  and  in  view  of  the  fact  that  the  spinal  absorbents 
are  shut  off  soon  after  birth,  this  is  conceivable.  The 
efforts  of  coughing  fill  up  the  brain  and  so  press  it  against 
the  cranial  absorbents  as  to  impede  their  efficient  action. 

But  this  theory  is  opposed  by  the  large  experience  of 
Heubner  (see  his  article  in  Eulenberg's  "  Cyclopsedie"). 

e.  This  classification,  however,  does  not  offer  from  the 
mechanical  stand-point  a  satisfactory  explanation  except  in 
part. 

To  these  forms  we  must  logically  add  another,  due  to 
obstruction  of  the  ultimate  absorbents  from  the  subarach- 
noid space,  whatever  the  nature  of  these  absorbents,  or  how- 
ever they  act  (v.  supra,  special  article).  The  occurrence 
of  suspended  material  in  some  cases,  that  must  be  carried 
along,  suggests  one  way  by  which  the  eventual  outlets  may 


/ 


64  CENTRAL   NERVOUS   SYSTEM. 

be  stopped  up.  The  local  inflammation  of  a  meningitis 
constitutes  another.  The  balloon-valve  principle  represents 
a  third.  This  last  could  not  be  accorded  much  importance 
so  long  as  not  only  cranial  but  also  spinal  absorbents  were 
supposed  to  exist.  But  it  has  already  been  shown  that  there 
are  no  spinal  efferents  after  the  first  weeks  of  infancy. 
Hence  any  distention  of,  or  increase  of  pressure  from  the 
side  of,  the  brain  proper  must  materially  interfere  with  the 
usefulness  of  the  remaining — i.e.,  cranial — outlets. 

Either  we  must  acknowledge  such  a  form,  or  else,  what 
is  equivalent  to  it,  a  relative  insufficiency  of  the  absorbents 
when  extra  demands  are  placed  on  them.  As  yet  we  do 
not  know  with  any  exactness  the  normal  rate  of  production 
of  the  cerebro-spinal  fluid,  and  still  less  the  quantitative 
.  ability  of  the  absorbents  to  carry  it  off.  Since,  however, 
the  spinal  absorbents  become  obsolete  soon  after  birth, 
while  as  yet  the  cranial  absorbents  {in  specie  the  Pacchionian 
villi)  have  not  acquired  the  scope  of  adult  and  later  life,  it 
is  clear  that  in  the  early  period  (infancy  and  childhood)  the 
ultimate  absorbents  are  very  much  restricted  and  their  quan- 
titative ability  may  far  more  readily  show  a  relative  insuffi- 
ciency. Herein  may  be  one  long-sought  reason  for  the 
greater  frequency  of  hydrocephalus  in  early  life.* 

*  The  matter  of  hydrocephalus  in  childhood,  aside  from  the  congenital  form, 
is  a  somewhat  different  one  from  that  in  adults.  Its  greater  frequency  is  due 
to  several  causes, — 

1st.  The  scant  absorbents,  peculiar  to  this  period,  as  just  pointed  out. 

2d.  The  narrowness  of  the  passages.  This  allows  of  their  occlusion, 
-}  whether  by  inflammatory  process,  pressure,  or  direct  plugging,  much  more 
readily  than  in  adults. 

3d.  To  a  slight  extent  it  may  be  due  to  the  yielding  nature  of  the  cranium 
at  that  age.  This  has  long  figured  as  a  favorite  cause,  but  it  bears  rather  on 
the  volume  than  the  frequency  of  the  effusion. 


CENTRAL   NERVOUS   SYSTEM.  65 

This  form  (e)  includes  c,  and  must  play  an  important  part 
in  b,  and  even  the  uncertain  d.  If  this  plan  were  strictly 
carried  out,  we  should  put  all  cases  of  internal  hydro- 
cephalus, congenital  as  well  as  acquired,  under  two  chief 
divisions,  corresponding  to  a  (central  retention)  and  e 
(arachnoidal  retention), — all  other  types  then  becoming  sub- 
forms,  according  to  their  etiology.  While  this  is,  without 
doubt,  a  correct  classification,  and  a  necessary  one  from  the 
mechanical  stand-point,  sufficient  facts  for  a  complete  study 
of  form  e  are  wanting. 

The  thorough  establishing  of  certain  provisional  forms,  as 
a  and  b,  is  an  almost  necessary  preliminary  to  the  general 
acceptance  of  such  a  division  as  that  just  indicated.  The 
accumulated  evidence  showing  the  reality  of  these  two  forms 
amounts  to  a  demonstration.  They  include  all  cases  due  to 
direct  interference  with  the  outflow  from  the  ventricles  of 
either  A,  the  cerebro-spinal  fluid,  or  B,  the  blood  in  the 
veins.  The  channels  for  such  discharge  will  now  be  briefly 
described. 

VENTRICULAR    EFFERENTS. 

A.  For  the  Cerebro-Spinal  Fluid. 

This  is  produced  by  the  choroid  plexuses  in  the  ventricles. 
That  from  the  paracceles  is  augmented  from  the  plexuses  in 
the  diaccele  and  metaccele  on  the  way  out. 

4th.  The  relatively  larger  size  of  the  emanating  vein  of  Galen,  as  compared 
with  that  in  adults  (from  the  writer's  observations  probable),  suggests  a  more 
important  rSle  for  the  ventricular  circulation  in  childhood.  There  is  likewise, 
according  to  Trolard,  more  cerebro-spinal  fluid,  comparatively,  than  in  the 
adult  up  to  the  senile  conditions.  But  it  is  possible  that  his  observation  is  ex- 
plained by  the  limitation  of  absorbents. 

5th.  The  provoking  causes,  such  as  tubercular  meningitis,  are  more  fre- 
quent in  the  early  years  of  life. 

5 


66  CENTRAL   NERVOUS   SYSTEM. 

I.  The  only  normal  exit  from  the  lateral  ventricles  is  per 
foramen  of  Munro,  third  ventricle,  aqueduct  of  Sylvius,  and 
fourth  ventricle.  From  this  last  to  the  general  subarachnoid 
space  there  are  the  metapore  (foramen  of  Magendie)  and 
the  lesser  aperturse  laterales  {a.  I.  ventriculi  quarti  of  Key 
and  Retzius,  foramina  Luschkse). 

Other  described  exits  from  the  ventricles  are  evidently 
artefacts. 

The  experimental  injections  of  Key  and  Retzius  in 
Sweden,  corroborated  by  Marc  See  in  France  and  by 
Fischer  and  Waldeyer  in  Germany,  have  furnished  the 
anatomical  proof  that  this  view,  previously  indicated  by 
Magendie  and  worked  out  by  Hilton  from  pathological 
cases,  is  correct. 

The  foramen  of  Magendie  is  described  as  an  opening 
through  the  tela  choroidea  inferior.  Magendie  gave  it  an 
average  breadth  of  two  to  three  lines.  Luschka  says  it  is 
often  six  lines  long  and  four  broad.  According  to  Wilder 
{Jrnl.  Nev.  and Mnt.  Dis.,  1886,  p.  207),  "Themesal  foramen 
of  Magendie  is  approximately  rhomboidal  in  outline,  about 
five  millimetres  wide  and  eight  to  ten  millimetres  long." 
Frequently  small  vessels  and  fibres  cross  this  opening  from 
oblongata  to  cerebellum. 

Renault,  Luschka  (185  5),  and  also  Key  and  Retzius  found 
that  in  the  horse,  and  perhaps  in  some  other  animals,  this 
posterior  aperture  is  normally  absent,  the  laterals,  however, 
being  so  much  the  larger. 

Key  and  Retzius  say  the  aperturse  laterales  empty  into 
the  cisterna  magna  cerebello-medullaris,  and  that  they  are 
so  filled  up  by  the  villi  of  the  plexus  choroideus  lateralis  as 
to  favor  the  exit  of  fluid  but  impede  the  reverse. 

Through  the  upper  part  of  this  aperture  on  each  side, 


CENTRAL  NERVOUS   SYSTEM.  67 

beside  the  median  line  of  the  anterior  two-thirds  of  the 
infravermis,  runs,  according  to  Luschka,  the  middle  portion 
of  this  plexus,  its  course  showing  the  necessary  existence 
of  an  opening. 

That  the  ventricular  fluid  flows  through  the  aqueduct  of 
Sylvius  into  the  fourth  ventricle,  and  then  out  through  the 
lateral  apertures  as  well  as  the  metapore,  was  practically 
shown  by  the  autopsy  recorded  on  p.  129,  Case  I.  Such 
cases  of  hemorrhage,  not  very  rare  in  any  pathologist's 
experience,  show  that  this  channel  is  the  natural  outlet.  Of 
course,  it  is  also  not  rare  at  autopsy  to  find  that  an  hemor- 
rhagic effusion  has  travelled  along  this  route,  but  in  just 
the  opposite  direction. 

2.  Possibly  also  by  certain  lymphatics.  Ependymal 
stomata  have  been  described.  It  has  even  been  assumed 
that  the  choroidal  villi  both  secrete  and  absorb  fluid.  Such 
efferents  are,  however,  uncertain,  and,  in  this  connection,  of 
scant  importance. 

"The  lymphatics  of  the  choroid  plexus  in  the  paracceles 
unite  (Arnold)  to  form  one  trunk,  following  Galen's  vein. 
In  the  ependyma  lymphatic  net-works  have  occasionally 
been  observed"  (from  author's  article  in  Buck's  "Reference 
Hand-Book").  Whether  such  exist  or  then  really  absorb 
ventricular  fluid  is  not  very  material,  since,  of  themselves, 
they  are  unable  to  head  off  an  hydrocephalus  when  the 
aqueduct-path  is  once  closed.  Hence  they  are,  at  most, 
but  accessory  exits.  It  is  a  question  of  the  natural  outlets 
for  the  fluid.  If  it  be  reabsorbed  locally,  then  it  does  not 
go  to  the  general  stock  of  cephalo-rachidian  liquor,  and 
apparently  fails  of  its  main  purpose.  Quincke's  experiments 
failed  to  show  such  absorption,  but  pointed  to  the  path  out 
as  above  described. 


68  CENTRAL   NERVOUS   SYSTEM. 

The  matter  of  the  ultimate  absorption  of  the  fluid  from 
the  subarachnoid  space  is  considered  in  a  special  article. 

B.  For  the  Blood. 

This  is  conducted  off  by  the  vein  of  Galen  and  its  afflu- 
ents, discharging  through  the  sinus  rectus.  Hence  the 
anastomotic  connections  of  this  vessel  and  its  branches 
acquire  a  considerable  importance.  It  receives  several 
accessions  from  the  cortex,  each  of  which  has  connections 
sufficient  to  provide  collateral  discharge  in  case  of  its  in- 
dividual occlusion.  Or  these  together  might  serve  as  sub- 
stitute efferents  for  the  main  trunk  of  Galen.  These  corti- 
cal branches  otherwise  play  no  part  in  hydrocephalus. 
The  main  question  hinges  on  the  real  ventricular  vessels, 
the  two  venae  intimae  (velars),  with  their  sources  in  the 
ccelian  walls,  and  the  venae  choroideae. 

I.  The  cortical  branches  of  Galen's  vein  are  the  basilar, 
the  supercerebellar,  the  suboccipital,  and  the  (azygos)  cal- 
losal. 

In  only  one-half  the  cases  in  man,  as  was  shown  by  the 
writer,  does  the  basilar  (the  largest  external  branch)  come 
up  around  the  resp.  crus  cerebri  to  empty  into  the  corre- 
sponding vena  intima  or  more  directly  into  the  vena  Galeni, 
Only  in  such  can  it  adapt  itself  as  a  collateral  and  serve  to 
convey  blood  in  the  opposite  direction  (i.e.,  out  of  the 
ventricle). 

The  suboccipital,  supercerebellar,  and  callosal  veins,  emp- 
tying at  about  the  same  point  as  the  basilar,  might  also  be 
available  as  anastomoses.  At  best  this  can  only  occur  when 
the  obstruction  is  strictly  limited  to  the  sinus  rectus  or  the 
adjacent  portion  of  the  short  trunk  of  Galen's  vein.  If  the 
obstruction  extends  peripherally  beyond  the  specified  venous 


CENTRAL   NERVOUS   SYSTEM.  69 

channel,  then,  of  course,  these  cortical  connections  cannot 
act  as  collaterals. 

But  in  one-half  the  cases  in  man  the  basilar  vein  has 
merely  a  nominal  connection  with  the  ventricular  vessels, 
and  then,  of  course,  is  not  available.  This  statement  refers, 
however,  to  the  individual  sides,  and,  as  in  a  given  subject 
this  vessel  frequently  takes  the  upper  course  on  one  side 
while  its  partner  of  the  opposite  side  remains  basal,  it 
follows  that  only  in  the  minority  of  cases  is  this  alternative 
outlet  for  the  azygous  vena  Galeni  altogether  wanting.  In 
this  latter  type  blockage  of  Galen's  vein  or  the  straight  sinus 
becomes,  from  an  anatomical  stand-point,  a  more  serious 
affair,  though  the  other  collaterals  mentioned  might  still 
suffice. 

2.  Velars, — the  ventricular  veins  in  the  strict  sense. 

Two  particular  lines  for  collateral  discharge,  in  case 
of  blockage  of  one  or  both  these  veins,  must  be  con- 
sidered. 

First.  The  one  is  by  means  of  the  subcornual  vein,  first 
specially  described  by  the  writer.  This  is  a  considerable 
vessel  that  arises  in  the  walls  of  the  inferior  horn,  connects 
freely  with  the  branches  of  the  choroidal  vein  in  the  fringe 
of  plexus  that  runs  down  the  infracornu  (much  as  the  an- 
terior and  middle  choroid  arteries  inosculate),  and,  after 
passing  out  at  the  extreme  lateral  tip  of  Bichat's  fissure, 
empties  into  the  basilar  vein.  It  was  possibly  by  this  round- 
about and  not  altogether  certain  inosculation  that  compen- 
sation was  established  in  Wenzel's  case  (v.  infra,  p.  87). 
As  a  general  thing,  however,  it  must  be  an  impractical 
substitute. 

Second.   Per  trans-albal  connections  with  cortical  veins. 

I  have  elsewhere  sought  to  show  that  the  velar  branches, 


70  CENTRAL   NERVOUS   SYSTEM. 

from  the  substance  of  the  hemispheres,  were  terminal 
vessels.  But  Hedon,  a  later  French  investigator,  claims 
that  these  veins  do  have  more  or  less  connection,  through 
their  fine  ramifications  in  the  brain-substance,  with  those 
discharging  at  the  brain-surface.  Even,  however,  granting 
such  connections, — and  I  have  seen,  as  well  as  drawn,  the 
particular  veinlets  for  which  he  makes  the  claim, — they  are 
very  small,  traverse  the  hemispheres  for  a  long  distance, 
and,  as  experience  amply  shows,  are  inadequate  for  collat- 
eral purposes. 

Two  facts  become  apparent  after  any  careful  considera- 
tion of  the  evidence  in  normal  and  pathological  cases.  First, 
that  in  practice  it  is  rare  to  find  a  case  with  compression,  or 
other  obstruction  to  the  current  in  the  straight  sinus  or 
Galen's  vein,  in  which  there  is  not  also  more  or  less  inter- 
ference with  these  possible  collaterals.  Second,  that  any 
considerable  disturbance  of  the  customary  venous  exit  from 
the  cceles  induces  a  marked  increase  in  the  production 
of  the  fluid,  anastomoses  or  no  anastomoses.  Perhaps  it 
also  changes  unfavorably  the  character  of  the  fluid  pro- 
duced. 

There  is  another  lesser  vein,  but  as  important  in  its 
smaller  field, — the  "floccular  vein,"  first  described  by  the 
writer.*  There  is  one  on  each  side.  It  derives  a  large 
branch  from  the  plexus  in  the  lateral  recess  of  the  fourth 
ventricle.  This  "  choroid  plexus  emerges  from  the  lateral 
recess  near  the  flocculus,  between  the  seventh  and  eighth 
nerves  anteriorly,  and  the  glosso-pharyngeal  posteriorly" 
(Sutton).  It  may  join  with  the  basilar  when  this  empties  at 
the  base. 

*  "Veins  of  the  Brain,"  pp.  36,  37. 


CENTRAL   NERVOUS   SYSTEM.  7 1 

THE   EFFECT   OF  OBSTRUCTION   OF  THESE  EFFERENT 

PASSAGES. 

A'.  At  Various  Points  in  the  Path  of  the  Ventricu- 
lar (Cerebro-Spinal)  Fluid. 

In  cases  of  tumor  in  any  of  the  ventricles  it  is  often 
difficult  to  make  out,  especially  after  removal  of  the  brain, 
how  much  blockage  there  may  have  been  to  either  class  of 
efferents  ;  and  hence  impossible  to  say  just  what  the  bear- 
ing of  the  case  may  be  on  the  matter  here  in  question. 
Some  cases  involving  the  paracoeles  will  be  given  later 
under  venous  obstruction. 

The  points  at  issue  can  best  be  determined  by  a  study 
of  obstruction  at  the  orifices  or  small  parts  of  the  passage. 
No  attempt  will  be  made  to  give  an  exhaustive  collection 
of  published  cases,  but  enough  from  accessible  sources  to 
illustrate. 

i.  In  troubles  in  the  lateral  ventricles,  associated  with  a 
collection  of  fluid,  the  exact  relation  of  the  two  often  can- 
not be  made  out.  Still,  it  is  easy  to  see  that  neoplasms, 
adhesions,  etc.,  may  impede  either  the  fluid  or  venous  dis- 
charge, and  so  in  principle  conform  to  what  will  be  shown 
farther  along. 

It  is  known,  since  Virchow's  description,  that  obstruction 
of  a  posterior  horn  causes  a  dilatation  of  the  part  cut  off. 
And  Bland  Sutton  has  described  {Brain,  October,  1886) 
similar  cystic  formations  from  obstructions  in  the  lateral 
recesses  of  the  fourth  ventricle.  In  the  latter  location  we 
must  assume  a  double  or  complete  closing-in  to  explain  a 
cyst,  unless  regarded  as  part  of  the  whole  ventricle.  In 
any  of  these  partial  forms  a  bit  of  choroid  plexus  must  be 
included  that  fluid  can  accumulate  therefrom. 

2.  At  the  Foramen  of  Munro. 


72  CENTRAL  NERVOUS   SYSTEM. 

As  it  is  by  this  passage  that  the  laterals  connect  with  the 
third  ventricle,  it  is  clear  that  its  closure  suffices  to  cut  off 
the  outlet  from  one  or  both  the  laterals,  and  so  dam  back 
their  discharge. 

Cases  of  sacculated  fluid  representing  a  part  of  one  ven- 
tricle have  just  been  referred  to.  When,  however,  the 
effusion  fills  the  whole  of  one  lateral  and  is  limited  to  that, 
there  is  a  closure  on  the  affected  side  of  the  opening  into 
the  third  ventricle.  Or,  as  Gowers  in  more  general  terms 
says,  when  "confined  to  one  or  both  lateral  ventricles, 
there  is  some  obstruction  at  the  foramen  of  Munro." 

i'.  In  Reynolds's  "System  of  Medicine"  a  case  is  given 
from  Vrolik  ("Traite  sur  1' Hydrocephalic  interne,"  Am- 
sterdam, 1839)  "of  a  young  man  who  died  from  chronic 
hydrocephalus  at  the  age  of  twenty,  and  in  whom  a  false 
membrane  had  occluded  the  foramen  of  Munro." 

2'.  Broxholm,  Lancet,  1853,  ii.  p.  349.  Woman  of 
twenty-seven  years.  No  premonitory  symptoms  except  a 
headache  for  twelve  hours.  "  On  removing  the  skull-cap 
about  a  pint  of  serum  escaped,  and  the  vessels  appeared 
very  much  congested  ;  the  sinuses  were  completely  en- 
gorged. On  slitting  down  the  brain  and  opening  the  lateral 
ventricles,  they  were  found  much  distended  with  fluid,  and 
between  the  layers  of  the  septum  lucidum  (the  fifth  ven- 
tricle) a  hydatid  cyst,  the  size  of  a  small  marble,  was  detected 
floating  in  fluid."  While  this  may  not  have  been  a  direct 
closure  of  Munro's  foramen,  it  evidently  had  that  effect. 

3'.  Forster  {Wurzburger  Med.  Ztschr.,  1864,  p.  39,  quoted 
by  Edes,  Med.  News,  1888,  i.  p.  61,  Case  I.)  :  "Ventricles 
found  moderately  enlarged,  filled  with  clear  water,  and  a 
growth  in  the  median  line  of  the  choroid  plexus,  which  had 
evidently  caused  the  hydrocephalus.     The  growth  was  in 


CENTRAL   NERVOUS   SYSTEM.  73 

the  middle  ventricle,  directly  at  and  partly  in  the  much- 
enlarged  foramen  of  Munro." 

4.'.   Edes's  own  case  {ibid.,  p.  62)  :  "  In  the  lateral  ven- 
tricles were   six   ounces   of  clear  serum.      In  the  choroid      X- 
plexus  and   directly  in  the  foramen  of  Munro  was  a  soft 
grayish,  rounded  tumor." 

5'.  W.  W.  Keen,  Med.  News,  September  20,  1890,  p. 
277,  Case  III.  :  "This  was  a  case  of  tubercular  meningitis, 
with  unilateral  acute  internal  hydrocephalus  of  the  left  ven- 
tricle. The  foramen  of  Munro,  as  determined  at  the  au- 
topsy, was  closed.  This  closure  was  attended  by  unilateral 
distention,  and  produced  right  hemiplegia." 

6'.  Baskett,  Brit.  Med.  Jrnl.,  1894,  i.  p.  63,  relates  a 
case  of  tapping  for  relief  of  a  congenital  hydrocephalus. 
After  this  there  was  a  gradual  but  unilateral  accumulation, 
due  to  plugging  at  foramen  of  Munro. 

3.    Third  Ventricle. 

Growths  here  rarely  obstruct  the  passage  for  fluid  with- 
out also  involving  the  veins  above,  or  possibly  irritating  the 
choroidal  fringes  and  so  limiting  their  significance.  Yet 
there  are  sufficient  cases  for  illustration. 

i'.  Coindet,  quoted  by  Lallemand  (p.  184  of  the  German 
edition  of  his  work  on  the  brain,  Leipzig,  1825).  Girl  of 
seven  months.  In  the  right  lateral  was  about  half  a  pound 
of  chocolate-colored  mixture  of  blood  and  brain-substance. 
The  left  ventricle  contained  nearly  twelve  ounces  of  clear 
serous  fluid.  No  trace  of  the  third  ventricle  ("  der  dritte 
Ventrikel  war  gar  nicht  mehr  vorhanden"). 

2'.  H.  Wallmann,  Virch.  Arch.,  1858,  Bd.  xiv.  p.  385. 
Man  of  fifty-two  years.  Colloid  cyst  of  third  ventricle  con- 
nected with    the  plexus  choroideus  medius  and  posterior 


74  CENTRAL  NERVOUS   SYSTEM. 

commissure.  It  measured  three  and  one-fifth  centimetres  in 
length  by  one  and  three-fifths  centimetres  in  breadth  and 
thickness.  It  was  situated  a  little  posteriorly  in  the  third 
ventricle,  and  this  ccele  was  formed  to  the  outlines  of  the 
tumor.  Great  internal  hydrocephalus.  As,  however,  the 
fornix  was  pressed  upward,  there  may  have  been  some 
vein-interference. 

3'.  Woodbury,  Am.  Jrnl.  Med.  Sc,  July,  1878  :  "Tumor, 
size  of  a  walnut,  found  in  the  ventricle,  moulded  to  the  in- 
terior." "A  caudate  prolongation  completely  blocked  the 
iter."  Fourth,  [?]  and  to  a  less  extent  lateral  ventricles 
enormously  distended. 

4!.  Bristowe,  Brain,  1884,  pp.  182-184,  Case  III.  :  "Much 
distention  of  lateral  ventricles  with  clear  fluid.  The  third  ven- 
tricle was  occupied  by  an  irregularly  globular  tubercular  mass, 
one  and  one-half  inches  in  diameter,  which  partly  involved 
both  optic  thalami."      Ended  with  tubercular  meningitis. 

$'.  In  Dana's  case  {Jrnl.  Nrv.  a,7id  Mnt.  Dis.,  1892,  p. 
217)  "there  was  no  great  excess  of  fluid  in  the  ventricles." 

4.  Aqueduct  of  Sylvius. 

A  narrow,  easily  occluded  passage.*     It  is  quite  as  prob- 


*  Boenninghaus  has  recently  ("  Die  Meningitis  serosa,"  Wiesbaden,  1897) 
described  what  he  calls  active  closure  of  the  ventricular  outlet  at  this  passage, 
— in  contrast  to  what  he  calls  passive  closure  by  actual  sealing  up  at  any  point 
along  the  ventricular  outlet, — and  attributes  to  this  many  cases  of  collection 
in  lateral  and  third  ventricles  to  the  exclusion  of  the  fourth.  He  conceives 
that  first  a  secretion  of  fluid  occurs  faster  than  the  aqueduct  can  carry  it  off. 
This  secondarily  so  drags  on  the  aqueduct  as  to  close  it.  Of  course,  in  such 
a  case,  after  removal  of  the  brain  nothing  remains  to  show  the  manner  of 
blocking.  He  also  applies  a  similar  scheme  to  the  outlets  from  the  fourth 
ventricle.  It,  however,  can  hardly  be  claimed  that  there  is  any  real  evidence 
in  favor  of  such  a  theory. 


CENTRAL   NERVOUS   SYSTEM.  75 

able  that  cerebellar  tumors  produce  an  aggregation  of  fluid 
in  the  paracceles  by  pressure  on  this  fine  exit,  as  on  the 
vein  of  Galen.  More  limited  and  unmistakable  obstruction 
of  this  duct  is,  however,  occasionally  recorded. 

i'.  Hilton,  "On  Rest  and  Pain,"  gives  the  post-mortem 
of  a  girl  of  seven  months,  who  had  been  hydrocephalic  since 
four  months  old.  "The  lateral  ventricles  were  distended, 
and  contained  four  ounces  of  fluid."  "The  iter  e  tertio  ad 
quartern  ventriculum  was  dilated  nearly  as  far  as  the  en- 
trance into  the  fourth  ventricle,  where  it  was  closed  by  old 
and  firm  adhesion.  This  occlusion  necessarily  preserved 
the  fourth  ventricle  from  dilatation,  and  it  was  accordingly 
natural  in  form." 

2'.  Bristowe,  Brain,  1884,  p.  188,  Case  V.  Man  of  sev- 
enteen years.  Lateral  ventricles  largely  and  uniformly 
dilated.  These  communicated  freely  with  the  large  and 
distended  third  ventricle.  The  commencement  of  the  iter 
was  quite  blocked  by  a  translucent  septum,  looking  like  a 
portion  of  the  ependyma.  The  fourth  ventricle  was  dis- 
tended with  fluid  and  formed  a  cyst  isolated  from  all  the 
other  cceles.  Oblongata  and  first  six  inches  of  cord  much 
enlarged,  but  quite  independently  of  the  fourth  ventricle. 

3'.  A  case  of  Taylor's  is  quoted  by  Goodhart,  of  London 
{Arch,  of  Pediatrics,  1888,  p.  39),  in  which  there  was  a 
congenital  hydrocephalus,  and  where  at  the  autopsy  the 
Sylvian  aqueduct  was  found  obliterated. 

4'.  Nothnagel  (  Wien.  Med.  Blatter,  1888,  No.  6,  v.  Centbl. 
f.  Med.  Wissc,  1888,  p.  578).  Man  of  seventeen  years. 
Besides  usual  symptoms  of  brain-pressure  there  was  a  re- 
peated outflow  of  cerebro-spinal  fluid  from  right  nostril  and 
even  eye.  A  firm,  hazel-nut-sized  tumor  of  the  corpora 
quadrigemina  was  found  pressing  down  on  the  aqueduct  of 


76  CENTRAL   NERVOUS   SYSTEM. 

Sylvius,  and  in  the  posterior  portion  completely  closing  it. 
The  ventricles,  except  the  fourth,  were  greatly  dilated  and 
filled  with  fluid. 

5r.  Chaffey,  Brit.  Med.  JrnL,  1891,  ii.  p.  224.  Tapping 
of  lateral  ventricles.  Death.  The  "  dilatation  was  doubt- 
less mainly  induced  by  a  caseous  deposit  at  the  summit  of 
the  transverse  fissure,  which  pressed  upon  and  constricted 
the  iter. "    Some  recent  tubercles  in  the  Sylvian  fissure  also. 

6'.  Jos.  Collins,  Am.  JrnL  Med.  Sc,  October,  1895,  pp. 
420-425.  Youth  of  eighteen  years.  Lateral  ventricles 
found  greatly  distended  (eight  to  ten  ounces  escaped), 
and  practically  continuous  with  third.  The  fourth  ven- 
tricle contained  no  fluid.  (At  another  point  he  speaks  of 
"  the  distention  of  the  fourth  ventricle,"  but  this  is  evi- 
dently a  mistake).  "  Grayish  translucent  mass  filling  the 
aqueduct  of  Sylvius  and  projecting  backward  like  a  tongue." 
It  extended  just  about  the  full  length  of  the  iter. 

y'.  In  marked  contrast  to  the  above  is  the  unique  case 
of  Quincke  (Volkmann's  "Sammlung,"  N.  F.,  No.  67,  1893, 
pp.  687,  688),  where  the  aqueduct  was  congenitally  closed 
(boy  of  about  six  months),  but  the  third  ventricle  in  some 
way  communicated  with  the  subarachnoid  space.  The 
lateral  ventricles  were  much  dilated. 

Tumors  of  the  quadrigeminal  region  are  rarely  in  point, 
as  they  so  easily  compress  both  the  iter  and  Galen's  vein. 
Typical  here  are  tumors  of  the  pineal  gland.  A  review 
of  the  cases  of  Birch-Hirschfeld,  Fontoppidian,  Reinhold, 
Schulz,  and  Zenner  fully  justifies  the  statement  of  the  latter 
{Alienist  and  Neurologist,  1892,  p.  470),  based  on  his  own 
and  nine  previous  cases.  "All  these  were  much  alike. 
Usually  the  tumor  was  described  as  the  size  of  a  walnut, 
and  as  pressing  on  neighboring  organs,  especially  the  cor- 


CENTRAL   NERVOUS   SYSTEM.  77 

pora  quadrigemina.  A  special  feature  was  pressure  on  the 
vena  Galeni,  or  aqueduct  of  Sylvius,  which  caused  internal 
hydrocephalus."  In  these  cases  the  fourth  ventricle  is,  of 
course,  not  included  in  the  hydrocephalus. 

5.   The  Fourth  Ventricle. 

This  is  the  next  stage  caudad  in  the  path  of  the  fluid. 
About  the  only  evidence  available  to  show  what  closure  of 
this  cavity  will  do  is  furnished  by  cases  of  local  neoplasm. 
Such  growths  may  not  suffice  to  cut  off  the  way.  Evi- 
dently this  was  the  condition  in  Schmidt's  case  {/ml.  Nerv. 
and  Mrit.  Bis.,  1882),  where  there  were  two  growths,  one 
on  each  side,  and,  in  the  absence  of  further  information, 
very  likely  also  in  that  of  Edes  {Boston  M.  and  S.  J.,  1896, 
ii.  p.  410). 

Audry,  in  his  article  on  tumors  of  the  choroid  plexus 
{Rev.  de  Medc,  Nov.,  1886),  recognizes  the  fact  that  they 
are  usually  complicated  by  hydrocephalus  due  to  vein  or 
fluid  obstruction.  In  seven  of  his  series  of  collected  cases 
it  is  specifically  stated  that  there  was  ventricular  accumu- 
lation with  tumor  of  the  metepiccele, — viz.,  in  the  cases  of 
(i')  Robin,  1858  ;  (2')  Levrat-Perroton,  1859  ;  (3')  Zenker, 
1871  ;  (4/)  Gar  rod,  1873;  (5 ;)  Recklinghausen,  1874;  (6') 
Spillmann,  1882;  and  (7')  Douty,  1885. 

8'.  Ogle,  Trans.  Path.  Soc,  London,  1856,  vol.  vii.  Boy 
of  eight  years.  Acute  hydrocephalus  from  exposure  to 
sun  three  years  previously.  Tough  membrane  surrounding 
a  cyst  of  the  whole  fourth  ventricle  ;  lateral  ventricles  very 
large,  containing  not  less  than  a  pint. 

9'.  Charles  Kelly,  ibid.,  1873,  vol.  xxiv.  Boy  of  eleven 
years.  A  papilloma  was  found,  very  much  distending  the  ven- 
tricle.   "  The  lateral  ventricles  were  full  of  clear  serous  fluid." 


78  CENTRAL  NERVOUS   SYSTEM. 

ic/.  Another  specially  good  case  is  given  by  Anton  ("Zur 
Anatomie  des  Hydrocephalus  und  des  Hirndruckes,"  Wien. 
Med.  Jahrb.,  1888,  quoted  by  G.  Levi,  Konigsberg  Dis- 
sertation, 1896).  Man  of  twenty  years,  who  had  suffered 
six  years  from  symptoms  of  brain-pressure.  An  echino- 
coccus  with  surrounding  thickened  tissue  completely  closed 
the  fourth  ventricle. 

nr.  Quincke,  "  Ueber  Meningitis  serosa,"  Leipzig,  1893, 
p.  684.  Male  of  twenty-one  years.  Duration  of  special 
symptoms  about  six  months.  Marked  hydrocephalic  dis- 
tention of  lateral  and  third  ventricles.  Aqueduct  of  Sylvius 
greatly  dilated.      Fourth  ventricle  filled  with  a  soft  glioma. 

I2r.  Ibid.,  p.  685.  Brief  reference  to  another  case  of 
hydrocephalus  due  to  a  cyst  in  the  fourth  ventricle,  origi- 
nating from  the  cerebellum. 

13'.  F.  Pick,  Ztschr.  f.  Heilkunde,  Bd.  xiii.  {v.  Neurlgc. 
Centbl,  1893,  p.  278).  Man  of  thirty-seven  years,  who 
had  presented  symptoms  of  brain-tumor.  Autopsy  showed 
a  complete  closure  of  the  fourth  ventricle  by  a  cicatricial 
formation  in  front  of  the  alae  cinerea.  This  involved  the 
ependyma  of  the  fovea  rhomboidalis,  the  anterior  extremity 
of  the  infravermis,  and  the  plexus  choroideus.  It  had 
produced  a  high  degree  of  hydrocephalus.  Etiology  un- 
certain. 

14'.  Bruns,  reported  in  Neurlgc.  Centbl.,  1895,  p.  521. 
Sarcoma,  size  of  a  medium  apple,  in  fourth  ventricle  of  a 
boy  of  five  years.  Symptoms  began  in  his  second  year. 
Enormous  hydrocephalus. 

15'.  Kretz,  "Tod  durch  Hydrocephalus  nach  intermenin- 
gealer  Blutung  aus  einem  Aneurysma  der  Arteria  carotis 
interna,"  Wiener  klin.  Wochr.,  1895,  No.  33  (v.  Neurlgc. 
Centbl.,    1896,  p.  655.)     Man  of  thirty-nine  years.      "The 


CENTRAL   NERVOUS   SYSTEM.  79 

cavity  of  the  fourth  ventricle  was  closed  by  adhesion  of 
the  tela  choroidea  to  the  fovea  rhomboidalis.  Chronic  hy- 
drocephalus." The  adhesions  were  attributed  to  a  heavy 
intermeningeal  hemorrhage  from  the  aneurism,  corre- 
sponding to  a  severe  apoplectic  attack  eight  months  ante- 
mortem. 

6.  The  observation  of  a  closure  of  the  cerebro-spinal 
foramen  (the  foramen  Magendie  of  Luschka,  Hilton's  canal, 
Apertura  inferior  ventriculi  quarti  of  Key  and  Retzius, 
Wilder's  metapore)  in  cases  of  hydrocephalus  has  been 
repeatedly  corroborated,  although  not  to  the  extent  of  find- 
ing this  particular  opening  obstructed  in  nearly  every  case, 
as  was  Hilton's  experience. 

1',  2',  and  3'.  According  to  Key  and  Retzius  (1875,  p. 
1 1 7),  Magendie  *  found  this  communication  closed  twice 
in  elderly  individuals.  There  was  an  abnormal  quantity  of 
fluid  in  the  ventricles  in  each  case.  Both  subjects  were 
insane. 

And  Magendie  cited  another  case  from  Martin  Saint- 
Ange.  This  occurred  in  a  child  of  eight  years.  There 
had  been  severe  cerebral  symptoms.  The  ventricles  were 
filled  with  much  serum,  and  the  foramen  of  Magendie  was 
closed  by  a  pretty  firm  opaque  membrane. 

4/  and  5'.  Hilton,  in  his  work  on  "Rest  and  Pain,"  pub- 
lished two  cases  more  in  detail,  the  first  dating  from  1844. 

6'  and  f.  Hanot  and  Joffroy,  Gaz.  Med.,  1873  {v.  Wer- 
nicke). Opacity  and  thickening  of  pia.  Posteriorly  the 
adhesions  were  so  strong  that  the  cerebellum  was  firmly 
attached  to  the  oblongata.      Dilatation  of  the  ventricles. 

*  Presumably  published  in  his  "  Recherches  sur  le  liquide  cephalo-rachi- 
dien,"  Paris,  1842,  although  I  have  not  been  ableito  see  the  original. 


80  CENTRAL   NERVOUS   SYSTEM. 

In  a  second  case  of  theirs,  a  man  of  seventeen  years  made 
a  relative  recovery  from  meningitis,  then  suddenly  died. 
The  cerebellum  was  so  closely  adherent  to  the  bulbus  that 
the  pia  had  to  be  cut  through  with  scissors.  Here  also  the 
fourth  ventricle  was  dilated. 

8'  to  23'.  At  the  London  Pathl.  Soc.  (meeting  of  Febru- 
ary 21,  1882  ;  abstract  in  Med.  Ti.  and  Gas.  of  March  4) 
several  cases  were  reported,  by  Drs  Baxter  (one),  Mackenzie 
(three),  and  Lees  (a  dozen  more). 

24'.  Bunce,  Edinburgh  Med.  Jrnl.,  March,  1887,  p.  838. 
Girl.  Simple  meningitis.  Apparent  recovery.  Convul- 
sions and  death.  "On  looking  at  the  under  surface  of  the 
cerebellum  and  medulla  the  fibrous  thickening  of  the  mem- 
brane had  formed  an  adhesion  between  the  two  sides  of 
the  latter  and  amygdala,  which  were  also  closely  united." 
"  Lateral  ventricles  were  found  considerably  distended. 
The  foramen  of  Munro  was  dilated  to  have  a  diameter  of 
about  half  an  inch."  "  The  third  ventricle  was  also  dilated, 
as  was  the  fourth.  The  pineal  gland  was  normal,  and  the 
two  veins  of  Galen  not  at  all  obstructed.  It  was  prob- 
able that  the  increase  of  fluid  was  due  to  the  blocking 
up  of  the  lymphatic  outlet  at  the  foramen  of  Magendie, 
caused  by  the  gluing  of  the  cerebellum  to  the  sides  of  the 
medulla." 

25'.  F.  Plehn  {Kiel  Dissertation,  1887)  gives  the  case  of 
a  student  of  twenty-three  years,  who  had  suffered  much 
from  cephalalgia  since  an  accident  in  his  tenth  year. 
Sudden  death  under  signs  of  suffocation.  Great  distention 
of  lateral,  third,  and  fourth  ventricles  by  fluid.  Aqueduct 
permeable.  Foramen  of  Magendie  obliterated.  Pia  in 
post-cerebellar  region  whitish,  opaque,  and  thickened. 

26'.   In   a  case  from  Dr.  Habershon's  service  at  Guy's 


CENTRAL   NERVOUS   SYSTEM.  8 1 

Hospital  in  1871  (No.  6  of  Fagge's  "System  of  Medicine," 
1888,  i.  p.  661)  Magendie's  opening  was  found  closed. 

27'.  Lawson,  of  Hull  {Brit.  Med.  Jrnl,  1893,  i.  p.  1322). 
One  case  of  evident  closure  of  foramen  of  Magendie  in 
connection  with  hydrocephalus. 

28'  and  29'.  Two  cases  of  hydrocephalus — one  in  a  boy 
of  thirteen  and  a  half  years,  and  the  other  in  a  girl  of  four 
years,  associated  with  complete  absence  of  communication 
between  the  fourth  ventricle  and  the  subarachnoid  space — 
have  recently  been  described  by  O' Carroll  [Trans.  Irish 
Acad.  Medc,  1894).  Here  it  is  specifically  noted  that  the 
lateral  exits  were  also  closed. 

30'.  Neurath,  Aerztl.  Central-Anzg.,  1895,  Wien,  vii.  p. 
521.  Boy  of  eleven  years.  Hydrocephalus  began  six  years 
before,  presumably  from  a  scarlatinal  leptomeningitis.  Brain- 
ventricles  were  greatly  distended,  and  contained  about  half 
a  litre  of  clear  fluid.  The  third  ventricle  bulged  downward. 
Aqueductus  Sylvii  distended  to  size  of  a  crow's  quill.  The 
fourth  ventricle  was  cystically  enlarged  to  size  of  a  nut. 
The  foramen  of  Magendie  was  closed  ;  the  arachnoidea 
and  pia  were  here  closely  grown  together  and  somewhat 
opaque.     No  dilatation  of  central  canal  of  cord. 

31'.  Key  and  Retzius  (1875,  p.  117)  give  a  case  where 
they  found  a  thin  film,  as  a  direct  continuation  of  the  tela 
choroidea  inferior,  closing  this  opening.  And  yet  there 
was  no  abnormal  effusion  in  the  ventricles.  They  specify 
that  it  was  certainly  not  of  inflammatory  or  neoplastic 
origin,  but  perhaps  embryonic.  On  page  122,  however, 
they  state  that  the  lateral  apertures  from  the  fourth  ven- 
tricle were  in  this  case  open. 

The  argument  of  most  writers  that,  because  every  case 
of  hydrocephalus  is  not  due  to  obstruction  at  just  this  point, 

6 


82  CENTRAL  NERVOUS  SYSTEM. 

such  a  cause  is  very  doubtful,  simply  ignores  the  fact  that 
this  particular  seat  of  obstruction  does  not  hold  for  all 
cases.  It  is  time  to  recognize  its  full  and  complete  validity 
wherever  found.  That  upon  the  very  principle  upon  which 
obstruction  at  this  point  acts,  there  are  plenty  of  cases 
where  the  particular  location  is  at  some  other  point,  is  an 
integral  part  of  the  explanation.  The  main  matter  in  this 
theory  is  further  not  affected  by  any  question  as  to  whether 
the  occlusion  be  limited  strictly  to  the  foramen  of  Magendie 
or  whether,  together  with  this,  the  other  small  adjacent 
communications  (aperturae  laterales,  more  or  less  filled  by 
choroid  plexus)  be  also  closed.  In  O 'Carroll's  two  cases 
the  latter  condition  was  found  ;  the  same  holds  for  Pick's 
case,  and  in  the  others  cited  there  is  fair  reason  to  conclude 
that  it  also  existed. 

While,  as  stated,  this  explanation  applies,  of  course,  only 
to  cases  in  which  such  obstruction  is  present,  it  harmonizes 
perfectly  with  that  for  the  previous  cases  of  interference 
higher  up,  and  goes  far  towards  establishing  a  general  theory 
of  obstructive  hydrocephalus. 

The  case  of  Key  and  Retzius,  where  with  closure  of  the 
foramen  of  Magendie  the  lateral  apertures  were  open  and  no 
fluid  stasis  occurred,  and  the  later  ones  of  O' Carroll,  where 
all  these  apertures  were  closed  and  the  stasis  did  occur, 
serve  to  definitely  round  out  the  picture  and  complete  the 
final  proof.  If  further  clinching  is  necessary,  it  is  afforded 
by  the  successful  results  of  English  operators,  to  which 
fuller  reference  will  be  made  under  treatment.  In  follow- 
ing out  this  view  to  its  practical  application  by  re-opening 
the  metapore,  they  have  achieved  a  fair  share  of  cures. 

A  natural  query  might  be,  What  becomes  of  the  con- 
tinual flow  of  ventricular  fluid  if  all  outlets  are  shut  off? 


^ 


CENTRAL   NERVOUS   SYSTEM.  83 

In  the  first  place,  it  is  possible  that  a  minimal  quantity 
may  pass  outward  through  the  surrounding  tissue,  or  by 
way  of  the  uncertain  ccelian  lymphatics  described  as  accom- 
panying Galen's  vein.  Another  portion  is  stored  up  in  the 
increasing  hydrocephalus.  For  the  most  part,  however, 
the  counter-pressure  must  greatly  retard  the  production  of 
the  fluid.  If  a  little  rise  in  venous  pressure  serves  to  mate- 
rially increase  the  production,  then,  per  contra,  a  resisting 
pressure  must  very  materially  check  it. 

B'.  From  Obstruction  to  the  Venous  Discharge. 

As  an  exclusive  cause  this  is  infrequent  and  less  effective 
than  interference  with  the  fluid-discharge.  The  principle 
plays  its  chief  part  in  those  numerous  cases  where  there  is 
partial  obstruction  to  both  the  venous  and  fluid  exits  from 
the  cceles. 

Our  first  knowledge  of  the  fact  that  internal  hydro- 
cephalus may  be  due  to  obstruction  of  the  vein  of  Galen 
is  credited  to  Whytt  ("  Observations  on  the  Dropsy  in  the  \. 
Brain,  by  Robert  Whytt,  M.D.,"  Edinburgh,  1768).  All  he 
says  is,  in  speaking  "  Of  the  Causes  of  a  Dropsy  in  the  Ven- 
tricles of  the  Brain,"  as  cause  3  :  "A  scirrhous  tumor  of  the 
glandula  pituitaria,  or  in  any  part  contiguous  to  the  ven- 
tricles of  the  brain,  by  compressing  the  neighboring  trunks 
of  the  absorbent  veins  will  prevent  the  due  absorption  of 
that  fluid  which  the  small  arteries  constantly  exhale,  and 
occasion  a  dropsy  in  the  brain,  in  like  manner  as  a  scirrhous 
liver,  spleen,  or  pancreas  are  often  the  cause  of  an  ascites. 
As  a  proof  of  this  we  may  observe  that  M.  Petit  often  found  \ 
the  glandula  pituitaria  scirrhous  in  those  who  died  of  a 
dropsy  of  the  ventricles  of  the  brain.  / 

"  In  one  case  I  met  with  a  hard  tumor  within  the  right 


84  CENTRAL   NERVOUS   SYSTEM. 

thalamus  nervorum  opticorum.  It  was  almost  as  large  as 
a  small  hen's  egg,  of  a  yellowish  color  within,  and  of  a  firm 
consistence." 

There  is  some  ground  to  question  Whytt's  claim  to 
recognition  here.  He  certainly  does  not  suggest  that  in- 
terference with  this  vein  increases  the  output  of  fluid,  but 
only  that  it  interferes  with  a  supposed  venous  absorption. 
Later  work  has  shown  that  the  veins  are  not  the  absorbents 
of  the  fluid.  Hence,  in  any  strict  sense,  much  of  the  credit 
belongs  to  later  men,  especially  as  regards  any  correct  in- 
terpretation of  facts. 

In  hunting  for  the  immediate  cause  of  any  obscure  case 
of  hydrocephalus  the  venous  outlets  from  the  cceles  should 
be  subjected  to  careful  scrutiny. 

The  peculiar  course  of  Galen's  vein,  as  observed  by 
Braune  and  described  by  the  writer,*  exposes  it  greatly  to 
compression.  Especially  will  any  encroachment  of  the 
post-cranial  fossa  exert  pressure  in  the  direction  of  least  re- 
sistance,— i.e.,  towards  the  incisura  tentorii.  This  com- 
presses the  vein  laterally  against  the  splenium,  and  hence 
in  the  most  effective  manner. 

Another  weak  spot  here  is  the  slit  through  the  tentorium, 
by  which  this  vein  discharges  into  the  beginning  of  the 
straight  sinus.  Pressure  upward  on  the  middle  of  the  ten- 
torium, or  even  against  the  falx  in  front  of  the  opening, 
must  tend  to  draw  the  slit  tighter,  and  so  shut  off  the  out- 
flow. 

*  Some  previous  illustrations  had  pictured,  more  or  less  correctly,  the  angle 
at  which  this  vein  enters  the  straight  sinus.  For  example,  it  is  fairly  well 
shown  in  the  work  of  Key  and  Retzius  (Erste  Halfte,  1875,  Taf.  vii.  Fig.  1). 
But  no  notice  had  ever  been  taken  of  it,  or  of  the  vein's  long  curve  around 
the  splenium. 


CENTRAL  NERVOUS   SYSTEM.  85 

i.  Walman,  Virch.  Arch.,  1858,  Bd.  xiv.  p.  385.  An  old 
soldier.  The  ventricles  were  found  dilated.  Under  the 
fornix  was  an  oval  tumor  the  size  of  a  nut.  It  was  adherent 
by  its  posterior  border  to  the  median  choroid  plexus,  and  was 
also  adherent  to  the  posterior  commissure.  (Possibly  this 
may  have  also  pressed  on  the  commencement  of  the  iter.) 
Lipoma  size  of  a  bean  in  right  lateral  plexus. 

2.  David  Newman,  Glasgoiv  Med.  Jml.,  September,  1882, 
p.  163,  Case  II.  Ventricular  hydrocephalus  due  to  throm- 
bosis of  Galen's  vein.  Man,  aged  fifty-five  years.  "  Until 
three  months  before  death  the  patient  enjoyed  perfect  health. 
Symptoms  began  with  vertigo,  lassitude,  disturbed  sleep  at  x 
night,  and  drowsiness  during  the  day  ;  but  patient  was  suffi- 
ciently well  to  follow  his  occupation  until  six  days  prior  to 
death,  when  he  suddenly  became  comatose,  and  showed 
evidence  of  left  hemiplegia,  and  afterwards  of  general  mus- 
cular paralysis.  There  were  no  convulsions  or  spasmodic 
movements,  but  slight  convergent  strabismus  was  noticed 
with  dilatation  of  pupils.  Sphincters  unaffected.  Slight 
recovery  of  mental  powers  two  days  before  death,  suc- 
ceeded by  sudden  relapse. 

"Post-mortem  Inspection. — External  appearance  presents 
nothing  remarkable.  Head. — The  bones  of  the  head  are 
firmly  united,  and  there  is  no  evident  increase  in  size,  nor 
are  the  eyeballs  protruded.  The  dura  mater  is  slightly 
thickened  and  unusually  tense.  The  superior  longitudinal 
sinus  is  empty.  The  Pacchionian  bodies  are  enlarged  and 
project  slightly  into  the  cavity  of  the  sinus.  There  are  no 
morbid  changes,  fatty,  atheromatous,  or  aneurismal,  in  the 
vessels  at  the  base  of  the  brain,  except,  perhaps,  a  suspicious 
yellow  spot  in  the  artery  of  the  fissure  of  Sylvius  on  the  left 
side.     The   cerebral   convolutions    are   flattened,   soft,   and 


86  CENTRAL   NERVOUS   SYSTEM. 

cedematous,  but  there  is  no  fluid  collected  in  the  arachnoid. 
The  lateral  ventricles  are  considerably  dilated  by  an  accu- 
mulation of  about  four  and  a  half  ounces  of  clear,  straw- 
colored  fluid  in  each  of  them.  The  structures  forming  the 
floor  of  the  lateral  ventricles  are  soft,  flattened,  and  cede- 
matous ;  the  choroid  plexus  is  unusually  vascular,  and  con- 
tains a  few  small  cysts,  and,  tracing  the  vessels  of  the  plexus 
backward,  a  small,  whitish,  moderately  firm,  and  adherent 
clot  is  found  in  the  vein  of  Galen,  close  to  its  union  with 
the  inferior  longitudinal  and  straight  sinuses  ;  the  throm- 
bosis does  not  pass  beyond  the  opening  of  Galen's  vein  ; 
and  it  may  be  observed,  further,  that  in  none  of  the  other 
vessels  or  sinuses  are  any  clots  seen.     Spinal  cord  normal." 

(Other  organs  of  the  body  showed  unimportant  or  no 
changes.) 

"  Chemical  and  Microscopic  Examination  of  Fluid  from 
Ventricles  of  Brain. — Fluid  of  a  straw  color,  sp.  gr.  1007, 
contains  .501  per  cent,  of  solid  matter,  and  on  microscopic 
examination  of  the  sediment  a  few  leucocytes  and  one  or 
two  crystals  of  cholesterine  and  margarine  are  seen. 

"Analysis  of  Fluid. 

Water 994-99 

Solids  : 

Albuminous  matter 91 

Fatty 26 

Alcoholic  extract  .41 

Other  organic  matter  (mostly  alcapton)     ...      .60 
Inorganic  salts 2.83 

1000.00" 

P.  165.  In  this  "case  the  patient  was  old,  the  progress 
of  the  disease  rapid,  and  there  was  no  enlargement  of  the 


CENTRAL   NERVOUS   SYSTEM.  87 

head  ;  and,  beyond  thrombosis  of  Galen's  vein,  and  as  a 
consequence  the  accumulation  of  fluid  in  the  ventricles, 
with  flattening  of  the  convolutions,  there  were  no  morbid 
changes  discovered  in  the  brain." 

"The  obstruction  to  the  venous  flow  from  the  choroid 
plexus,  etc.,  was  complete,  and  evidently  sudden." 

P.  167.  "In  all  the  cases  we  have  found  recorded,  the 
thrombi  have  passed  beyond  Galen's  vein  into  the  straight, 
lateral,  or  longitudinal  sinuses,  so  that  the  case  above  de- 
scribed seems  to  be  quite  unique." 

The  moderate  degree  of  distention  in  this  case  may  have 
been  due  to  the  unyielding  cranium,  or  in  part,  at  least,  to 
that  cause. 

3.  J.  Stedman  (Bost.  M.  and  S.  J.,  August  9,  1883,  and 
1891,  vol.  i.  pp.  82,  83,  Case  IV.).  "Lateral  ventricles  dis- 
tended at  least  a  third  larger  than  usual,  and  filled  with 
clear,  watery  fluid."  "A  gray,  gelatinous  tumor,  the  size 
of  a  filbert,  was  found  upon  the  velum  interpositum,  in  the 
median  line,  behind  the  fifth  ventricle,  in  the  region  of  the 
anterior  commissure,  on  a  level  with  the  junction  of  the 
corpora  striata  and  optic  thalami."  A  cystic  tumor  easily 
removed  from  its  surroundings.  "The  structure  and  seat 
of  the  tumor  suggested  its  origin  from  the  choroid  plexus ; 
its  position  upon  the  venae  Galeni  (velars  ?)  explained  satis- 
factorily the  dropsy  of  the  ventricles." 

4.  K.  Wenzel,  "Ein  Fall  von  Hydrocephalus  internus 
chronicus  acquisitus."     Bonn,  1886. 

It  has  been  claimed  that  in  this  case  Magendie's  foramen 
was  closed,  but  a  careful  reading  of  the  original  fails  to  find 
any  proof  that  such  was  the  fact. 

The  patient  was  a  girl,  three  and  one-third  years  old  at 
death  ;  bottle-fed  as  infant ;  convulsions  at  ten  weeks  and 


88  CENTRAL   NERVOUS   SYSTEM. 

beginning  hydrocephalus  three  months  later, — due,  as  he 
concludes,  to  a  leptomeningitis  infantum.  Puncture  of 
ventricle  was  first  practised  three  and  a  half  months  before 
death.  This  yielded  a  non-inflammatory  fluid,  of  which  a 
detailed  analysis  is  given.  A  second  puncture  was  also 
made. 

At  the  autopsy,  one  to  one  and  a  half  litres  of  fluid 
came  from  the  enormously  dilated  lateral  ventricles.  "  The 
pia  at  the  base,  especially  from  chiasm  to  pons,  was  much 
thickened,  firm,  and  opaque  ;"   but  there  were  no  tubercles. 

"Very  numerous  and  noticeable  small  veins  run  from  the 
large  ganglia  [central]  up  and  outward  on  the  lateral  wall  of 
the  paracceles.  .  .  .  The  plexus  choroideus  was  of  a  lively 
red,  rolled  almost  together,  and  quite  granular  and  firm. 
It  doubled  around,  following  the  fimbria  fornicis  from  the 
infracornu,  shrunk  up  noticeably  opposite  the  thalamus,  and, 
turning  towards  the  quadrigemina,  vanished  without  con- 
tinuing out  in  a  median  portion.  From  this  extremity  of 
the  plexus,  veins  pass  outward  which  correspond  in  part  to 
the  stria  terminalis  ;  and  it  appears  that  blood  can  be  forced 
from  the  end  of  the  plexus  into  these  above-described  veins 
running  up  and  outward.  Nothing  is  to  be  seen  of  a  median 
choroid  plexus.  Third  ventricle  very  wide  ;  anterior  and  pos- 
terior commissures  intact.  .  .  .  The  floor  of  the  fourth  ven- 
tricle is  formed  of  a  translucent,  very  compact,  and  resisting 
membrane.  .   .   .   Fourth  ventricle  showed  no  abnormity." 

"  From  the  front  upper  extremity  of  the  cerebellar  supra- 
vermis  to  the  splenium  corporis  callosi  stretched  a  firm 
fibrous  membrane,  completely  closing  up  the  great  brain- 
fissure.  .  .  .  There  was  a  compact,  stout  adhesion  between 
corpora  quadrigemina  and  under  surface  of  splenium.  .  .  . 
These  changes  had  completely  obliterated  the  vena  magna 


CENTRAL   NERVOUS   SYSTEM.  89 

Galeni.  In  consequence  of  this  obliteration  there  was  a 
progressive  degeneration  of  the  plexus  choroideus  medianus 
and  of  the  plexus  choroideus  lateralis  up  to  the  point  where 
the  physiologically  preformed  collateral  path  to  the  vena 
striae  terminalis  admitted  the  formation  of  a  collateral  out- 
let. .  .  .  We  are  not  justified  in  assuming  a  stasis  in  the 
realm  of  the  cerebro-spinal  fluid,  as  the  aqueductus  Sylvii 
was  wide,  and  otherwise  no  reason  anatomically  for  this 
assumption  was  found." 

Evidently  in  this  case  the  venous  compensation  was 
either  by  connections  with  the  basilar  trunks  resp.  the  sub- 
occipital veins  near  their  junction  with  the  vena  Galeni  or 
by  way  of  the  infracornual  veins. 

5.  My  own  case  (v.  supra,  p.  42)  is  an  excellent  illustra- 
tion of  the  effect  of  interference  to  the  local  venous  dis- 
charge. Possibly  it  may  be  the  only  recorded  case  of 
obstruction  limited  to  the  straight  sinus. 

6.  My  second  case  (v.  supra,  p.  45)  is  scarcely  less 
apposite,  though  the  possibility  of  further  tubercular  irrita- 
tion can  hardly  be  denied. 

7.  J.  Audry,  Revue  de  Medc,  1886,  No.  11,  Case  I. 
Man  of  forty-five  years.  No  tubercular  or  other  meningeal 
trouble.  On  incising  the  border  of  the  tentorium  a  large 
quantity  of  clear  fluid  escaped.  In  the  left  ventricle,  at- 
tached to  the  choroid  plexus,  above  the  thalamus  was  a 
mobile  tumor  the  size  of  a  small  nut.  No  apparent  com- 
pression of  thalamus  or  ventricular  walls.  He  classes  the 
fluid  as  an  intense  ventricular  hydrocephalus,  due  to 
serious  interference  with  the  vascular  circulation  of  the 
plexus. 

8.  Ransom,  La?tcet,  July  1,  1893,  p.  15.  Man  of  twenty- 
three  years.      Lived  for  a  month  after  onset  of  symptoms. 


90  CENTRAL   NERVOUS   SYSTEM. 

"  The  lateral  ventricles  were  distended  with  fluid  to  twice 
their  normal  size.  .  .  .  The  foramina  of  Munro  were  much 
enlarged,  as  was  also  the  fourth  ventricle.  On  the  velum 
interpositum  there  was  a  patch  of  firm,  fibrous  thickening 
the  size  of  a  three-penny  piece,  apparently  obstructing  the 
veins  of  Galen." 

In  tumors  of  the  cerebellum,  or  pressure  from  the  poste- 
rior fossa,  any  attendant  hydrocephalus  is  usually  attributed 
to  compression  of  this  vein.  In  reality  it  may  as  well  be 
due  to  like  action  on  the  aqueduct.  Both  factors  doubt- 
less combine.  But  that  vein  obstruction  alone  may  suffice 
is  shown  by  the  cases  given.  It  is,  however,  probable  that 
this  produces  only  a  moderate  hydrocephalus. 

It  is  quite  possible  that  the  fluid  from  venous  stasis  here 
carries  formed  elements  or  precipitable  fibrin  that  stops  the 
ultimate  absorbents.  The  recent  observations  of  Went- 
worth  (Bost.  M.  and  S.  /.,  August  6  and  13,  1896)  show  that 
the  fluid  from  inflammatory  processes  differs  from  the  nor- 
mal by  its  invariable  cloudiness.  This  was  due  to  a  finely 
divided  sediment  suspended  in  the  fluid  and  found  to  con- 
sist of  mono-  and  polynuclear  cells.  After  standing  for 
a  few  hours  it  contained  more  or  less  fibrin,  evidently  of 
inflammatory  origin.  Quincke  reports  similar  findings  as 
frequent  in  so-called  meningitis  serosa. 

But  as  already  indicated,  the  collection  of  fluid  from 
venous  stasis  may  well  be  dependent  on  relative  insufficiency 
of  the  ultimate  absorbents  ;  and  either  way,  the  balloon- 
valve  principle  plays,  secondarily  at  least,  an  important 
part  in  this  form. 

In  cases  of  closure  of  the  sinus  rectus,  Galen's  vein  or 
the  velars,  three  possible  outcomes  are  to  be  thought  of : 

1.   Full  physiological  compensation. 


CENTRAL   NERVOUS   SYSTEM.  9 1 

2.  An  increase  of  ventricular  fluid,  leading  to  hydro- 
cephalus. 

3.  Early  death. 

1.   Perfect  Compensation. 

There  appears  to  be  no  evidence  to  show  that  this  can 
occur. 

2.  Hydrocephalus. 

The  ample  anastomoses  above  described,  and  the  fact 
that  normally  this  venous  current  has  to  turn  several  sharp 
angles  before  leaving  the  skull,  make  it,  at  first,  unintelli- 
gible why  there  should  ever  be  any  trouble  following  the 
closure  of  the  sinus  rectus  or  its  practical  extension,  the 
single  trunk  of  Galen's  vein.  And,  so  far  as  concerns  either 
the  vitality  of  the  tissues  or  the  function  of  the  brain-  and 
nerve-substance  proper,  there  is  nothing  to  show  that  compen- 
sation is  less  perfect  than  where  other  brain-veins  are  closed. 

The  difference  depends  entirely  on  the  presence,  in  the 
territory  of  this  vein,  of  a  peculiar  structure,  the  choroidal 
tissue,  occurring  only  in  the  brain-ventricles.  This  tissue 
normally  produces  ventricular  fluid.  Its  activity  is  easily 
influenced  by  many  conditions,  and  it  responds  quite  natu- 
rally to  any  interference  with  the  venous  discharge  by  an 
increased  production  of  fluid. 

It  is,  then,  not  primarily  any  venous  stasis  that  causes 
symptoms,  but  only  the  secondary  hydrocephalus.  And  the 
facts  show  that  this  is  always  bound  to  occur.  This  causes 
death,  if  at  all,  only  after  a  lengthy  period  and  in  this  indi- 
rect manner. 

3.   Early  Death. 

If,  however,  the  velars  are  closed  (i.e.,  the  venae  intimae 
be  cut  off  from  the  regular  outlet  and  from  the  collaterals 


92  CENTRAL   NERVOUS   SYSTEM. 

mentioned  on  page  68),  then,  so  far  as  present  evidence 
goes,  a  speedy  fatal  ending  is  inevitable.  This  takes  place 
before  there  is  time  for  the  development  of  much  hydro- 
cephalus, a  small  quantity  of  blood-tinged  fluid  being  all 
that  has  accumulated. 

Up  to  1884  the  writer  was  able  to  collect  three  such 
American  cases  ("Veins  of  Brain,"  p.  74),  and  those  from 
foreign  sources  were  merely  corroborative. 

It  is  still  possible  that  if  only  the  main  trunk  of  one  or 
both  velars  was  obstructed,  and  the  thrombosis  did  not  ex- 
tend into  any  of  their  branches,  the  fatal  ending  might  be 
delayed,  but  hardly  for  long. 

TREATMENT. 

In  view  of  the  unsatisfactoriness  of  medical  remedies, 
even  though  occasionally  successful,  it  is  well  to  inquire 
specially  what  surgical  indications  can  be  made  out,  and 
how  far  they  can  be  met.  In  this  regard  there  is  a  consid- 
erable difference,  according  to  the  form  or  type.  In  each 
of  these  it  will  be  necessary  first  to  formulate  some  plan 
for  making  a  diagnosis  of  the  form  itself.  This  desideratum 
cannot  be  very  well  met  as  yet,  but  it  may  be  in  order  to 
suggest  some  of  the  possible  ways  of  working  it  out. 

The  fact  that  numerous  cases  have,  at  one  time  and  an- 
other, been  reported  in  which  something  sudden  has  hap- 
pened, and  a  full  cure  resulted,  is  a  further  incentive  on 
the  surgical  side. 

Direct  puncture  of  the  brain  (said  by  Keen  to  date  back 
to  the  case  of  Dean  Swift  in  1744),  or  aspiration  of  the 
ventricles,  is  a  very  crude,  inadequate,  and  unsatisfactory 
procedure.  Relief  is  but  temporary,  and  the  danger  of 
inducing  a  meningitis  is  increased  by  prolonging  the  drain- 


CENTRAL   NERVOUS   SYSTEM.  93 

age.     This  is  the  general  verdict,  and  of  itself  the  method 
does  little  towards  re-establishing  normal  conditions. 

And  yet  Boenninghaus  (/.  c.)  has  been  able  to  collect 
four  cases,  including  one  of  his  own  (three  of  serous  and 
one  of  slightly  cloudy  fluid),  that  were  cured  in  this  way. 
Moreover,  in  infants  it  can  be  practised  through  an  angle 
of  the  fontanelle  without  trephining. 

Wherever  a  trial  lumbar  puncture  shows  pus,  germs,  re- 
tained blood,  or  any  coarse  products  of  inflammation,  it  is 
not  to  be  expected  that  incisive  measures  will  avail. 

1.  Where  the  collection  is  due  to  an  impaired  outflow 
from  the  fourth  ventricle. 

What  clinical  evidence  can  we  secure  to  show  that  a 
given  case  is  of  this  type  ? 

On  spinal  puncture  we  shall  find  the  fluid  there  under 
only  ordinary  pressure  (merely  nominal).  We  shall  fail  to 
secure  more  than  the  normal  surplus  or  residual  quantity 
there  retained  (shown  on  page  58  to  be  in  adults  one  to 
one  and  a  half  ounces),  and,  finally,  what  we  obtain  is 
perfectly  limpid,  clear  cerebro-spinal  fluid  minus  floating 
particles,  essentially  free  from  formed  elements.  A  micro- 
scopical and  brief  chemical  examination  of  the  fluid  ob- 
tained by  such  trial-puncture  is  necessary. 

There  may  also  be  increased  spinal  reflexes,  due,  per- 
haps, to  pressure  of  the  fluid  on  the  inhibitory  tracts. 

Various  casual  matters  in  individual  cases  may  furnish 
additional  clues. 

As  yet  these  seem  to  be  the  only  determining  marks 
that  we  have. 

Here  lumbar  puncture  is  absolutely  useless,  if  not  de- 
cidedly injurious,  except,  of  course,  for  diagnostic  purposes. 
In  these  cases,  be  the  obstruction  at  Magendie's  foramen 


94  CENTRAL   NERVOUS   SYSTEM. 

or  at  any  point  above,  it  is  clear  that  the  sacculated  fluid 
will  not  be  reached,  but  only  given  (by  reduction  of  counter- 
resistance)  a  more  favorable  opportunity  to  increase  locally. 

The  method  has  been  found  particularly  dangerous  in 
cerebellar  growths,  quite  likely  by  allowing  more  direct 
mechanical  action  on  the  centres  in  the  floor  of  the  fourth 
ventricle. 

But  there  is  here  a  legitimate  field  for  surgical  effort. 
An  opening  should  be  effected  in  the  occluding  tissue, — 
not  simply  a  slit  made,  but  a  good  hole  cut  out.  This 
need  involve  no  hemorrhage  beneath  the  dura.  It  should 
aim  to  re-establish  (antochthonous)  drainage.  There  is  a 
question  whether  perfectly  normal  paths  would  be  secured 
even  in  this  way.  Apparently,  an  unnatural  opening  would 
be  left  between  subarachnoid  and  subdural  spaces.  Prac- 
tically, this  can  be  neglected. 

It  is  certain  that  if  there  be  cerebellar  tumors,  the  same 
fatal  termination  will,  without  great  care,  follow  as  has  oc- 
curred from  spinal  puncture.  This  and  the  necessity  for 
establishing  but  slow  and,  if  possible,  intra-arachnoidal 
drainage  are  the  most  serious  features  of  the  operation. 

Something  of  the  sort  has  already  been  done  in  England. 
Alfred  Parkin,  of  Hull  {Lancet,  1893,  ii.  pp.  21  and  1244), 
on  September  13,  1892,  operated  a  case  of  tubercular  men- 
ingitis by  trephining  the  occipital  bone  in  the  median  line, 
opening  through  the  dura  and  lifting  the  cerebellar  border 
so  as  to  free  the  passage  beneath.  But,  despite  relief,  this 
soon  ended  fatally.  Later  he  did  a  successful  case  in  a 
child  of  fourteen  months.  "The  horse-hair  drain  was  re- 
moved eighteen  days  after  the  operation,  no  fluid  having 
come  away  for  three  days  before  its  removal  !"  A  diagram 
of  the  part  to  operate  is  given.      He  provides  for  gradual 


CENTRAL   NERVOUS   SYSTEM.  95 

withdrawal  of  fluid  by  first  lifting  the  edge  of  cerebellum 
enough  to  let  out  a  little  fluid  only,  and  then  draining  by 
a  few  strands  of  silk  or  the  like. 

As  he  says,  "Whether  the  openings  between  the  fourth 
ventricle  and  the  subarachnoid  space  are  patent  or  not,  they 
can  easily  be  made  so." 

Lawson,  /.  c,  in  his  case  also  drained  the  fourth  ven- 
tricle per  occiput,  but  too  freely,  and  death  ensued  in  a  few 
hours. 

Ord  and  Waterhouse,  Lancet,  1894,  i.  p.  597.  "A  Case, 
diagnosed  as  Tubercular  Meningitis,  treated  by  Trephining 
and  Drainage  of  the  Subarachnoid  Space ;  Recovery." 
Girl  of  five  years.  Operated  more  from  the  side  ;  a  bent 
sound  was  then  passed  in  on  the  flat,  and,  when  opposite 
the  occlusion,  turned  and  used  to  make  an  opening.  Drain- 
tube  left  in  for  eighteen  days. 

Glynn  and  Thomas,  of  Liverpool,  Lancet,  1895,  "'•  P- 
1 106.  "Case  of  Hydrocephalus  ;  Trephining  ;  Opening  the 
Fourth  Ventricle  ;  Recoveiy. "  In  this  case,  "something  to- 
wards the  fourth  ventricle"  was  ruptured  by  finger.  Man  of 
eighteen  years.  Symptoms  one  and  a  half  years.  Drain- 
tube  removed  on  the  fourth  day. 

These  English  operators  have  made  an  admirable  ad- 
vance. But  many  details  of  the  method  and  the  extent  of 
its  applicability  remain  yet  to  be  worked  out. 

2.   Where  the  obstruction  is  in  or  between  the  ventricles. 

Points  for  differential  diagnosis  of  this  type  from  the  pre- 
ceding are  lacking.  Of  course,  the  results  of  a  trial  lumbar 
puncture  will  be  the  same  as  though  the  block  was  at  Ma- 
gendie's  foramen.  And  the  state  of  the  spinal  reflexes  will 
hardly  show  a  material  difference. 

Here  it  is  hard  to  see  what  surgery  can  offer.     In  most  of 


96  CENTRAL   NERVOUS   SYSTEM. 

the  cases  the  retention  is  due  to  morbid  growths,  and  the 
treatment  becomes  that  of  the  causal  trouble.  In  other 
cases  there  is  a  chance,  according  to  Boenninghaus's  statis- 
tics, of  effecting  a  cure  by  direct  brain  puncture  and  with- 
drawal of  fluid. 

From  his  figures,  it  appears  that  about  one  case  in  six, 
taken  as  they  come,  has  yielded  a  cure,  but  there  is  no  evi- 
dence that  the  cases  were  of  this  class. 

3.  The  irritative  or  inflammatory  form,  also  that  due  to 
compression  of  the  venous  discharge  from  the  ventricles, 
and  apparently  many  congenital  cases  (all  included  under 
the  form  e,  of  p.  63). 

In  these  the  fluid-accumulation  reaches,  of  course,  down 
the  spinal  sac  (subarachnoidal).  Hence  a  trial-puncture 
(lumbar)  may  show  a  higher  pressure  of  the  fluid, — and 
Quincke  notes  that  this  is  common  in  meningitis  serosa. 
We  can  also  get  more  than  the  normal  reserve  quantity ; 
and  the  fluid  itself,  at  least  in  the  inflammatory  form,  will, 
according  to  Wentworth,*  show  even  microscopically  float- 
ing particles  and  corresponding  slight  turbidity. 

Whether  the  like  holds  for  the  form  due  exclusively  to 
venous  stasis  has  not  been  shown,  but  presumably  it  may. 
The  result  of  Quincke's  injections  in  living  animals  showed, 
pretty  conclusively,  that  fine  suspended  material  is  sufficient 
to  block  the  ultimate  absorbents. 

Where  trial-puncture  gives  fluid  that  is  turbid  or  con- 
tains inflammatory  products,  the  arachnoidal  form  is  prob- 
able. 

*  Previously  to  him  Huguenin  had  proposed  similar  distinguishing  marks 
(physical  and  chemical),  but  their  value  has  been  generally  disputed.  Possibly 
a  fluid,  at  first  showing  these,  may  gradually  settle  itself  clear,  resp.  carry  them 
along  to  block  up  the  outlets,  and  be  replaced  by  normal  fluid. 


CENTRAL   NERVOUS   SYSTEM.  97 

Cultures  or  examinations  for  infective  germs  are  proper, 
though  rarely  giving  positive  results  in  chronic  cases.  A 
chemical  examination  also  (v.  supra,  special  article  by  Bart- 
ley)  may  give  further  aid  in  diagnosis. 

In  this  form,  as  the  spinal  centres  are  subjected  to  direct 
pressure  by  the  fluid,  we  may  expect  to  find  the  correspond- 
ing reflexes  weakened,  or  not  increased. 

In  congenital  and  early  forms  the  presence  of  a  spina 
bifida  indicates  arachnoidal  rather  than  central  retention. 

Here  the  first  measure  to  be  thought  of  is  lumbar 
puncture.  Even  in  such  cases,  however,  this  is  not  a 
radical  measure,  and  rarely  gives  more  than  symptomatic 
relief. 

In  all  this  class  there  is  evidently,  as  indicated  above,  a 
clogging  up  of  the  arachno-absorbents.  Occasionally  in 
recent  cases  we  might  have  some  clearing  out  of  these,  just 
as  we  get  an  increased  absorption  after  tapping  a  pleurisy,  or 
by  a  letting  up  of  the  balloon-valve  if  that  principle  holds. 
But  in  most  cases  the  trouble  has  lasted  so  long  that  the 
interference  has  become  permanent. 

In  the  acute  form  the  causal  trouble  (where,  as  a  rule,  a 
tubercular  meningitis)  is  the  main  thing,  and  the  effusion 
merely  a  sequel  of  scant  moment. 

Simple  opening  of  the  cerebral  dura  has,  according  to 
Boenninghaus  (/.  c,  p.  65),  been  successful  in  four  cases, — 
one,  however,  supposed  to  have  been  only  a  subdural  cyst. 
Such  slitting  of  the  dura  has,  Boenninghaus  thinks,  the  same 
action  as  lumbar  puncture.  But,  as  it  gives  such  a  free  vent 
to  the  fluid,  it  represents  a  much  more  radical  method. 
The  indications  therefore,  however,  are  almost  identical 
with  those  for  spinal  puncture  considered  as  a  remedial 
operation. 

7 


98  CENTRAL   NERVOUS   SYSTEM. 

The  following  case  illustrates  well  this  method  of  pro- 
cedure : 

On  April  28,  1897,  I  was  asked  by  Dr.  William  Maddren  to  see  a  boy  of 
two  and  a  half  years.  The  child  had  been  brought  up  on  the  bottle,  entirely 
so  after  the  first  six  weeks  of  infancy.  Ancestry  healthy.  One  other  child,  a 
girl  of  nearly  five  years,  is  healthy, — except  that  she  is  over-stout  and  has  a 
large  head  (fifty- three  centimetres  in  maximum  circumference). 

The  boy  had  been  well  and  robust  up  to  two  months  ago.  At  that  time  he 
had  an  attack  of  night-terrors,  fever,  and  convulsions.  Since  then  he  has  eaten 
poorly,  been  more  restless,  not  slept  as  quietly,  and  in  playing  about  the  floor 
has  shown  a  peculiar  fear  of  all  small  objects  (as  feathers,  fur,  dust,  etc.),  call- 
ing them  mice.     Twice  during  this  period  he  vomited  a  little  mucus. 

Two  weeks  ago  he  had  a  slight  fall,  striking  the  back  and  left  side  of  the 
head.  There  was,  however,  no  visible  injury.  He  ran  about  after  this,  but 
the  same  day  towards  night  his  left  leg  gave  out.  This  disappeared,  but 
recurred  intermittently  afterwards,  especially  towards  evening.  These  two 
weeks  he  has  been  steadily  failing,  has  an  irregular  fever,  once  reaching  103 -|~°, 
objects  to  being  handled,  and  has  vomited  repeatedly.  Some  coughing. 
Cheyene-Stokes  respiration  the  last  two  days.  Involuntary  urination.  No  ear- 
trouble. 

The  patient  is  a  plump  boy,  with  a  good,  healthy  color.  He  lies  in  a 
stupor,  continually  turning  his  head  from  side  to  side  and  moaning.  At  every 
effort  to  move  him  he  cries  "Don't,"  but  that  is  his  only  distinct  utterance. 
The  pulse  varies,  often  ranging  from  96  to  132,  but  is  otherwise  regular.  Tem- 
perature 102. 2°  in  rectum.  No  retraction  of  head,  nor  contraction  of  neck- 
muscles,  except  that  he  resists  everything. 

Tache  cerebrale  is  well  marked  on  stroking  chest.  Respiratory  sounds 
normal.  Splenic  dulness  six  and  a  half  centimetres  long.  Abdomen  not 
retracted.  Epigastric  and  abdominal  reflexes  present.  Knee-jerks  doubt- 
ful or  absent.  Left  leg  resists  less  than  right,  and  only  the  left  can  be  well 
flexed  on  the  abdomen.  Pupils  wide  even  on  illumination.  Photophobia. 
Retina?  both  show  a  good  pink  ;  but  the  vessels  are  not  clear,  the  disks  are 
almost  obscured,  and  the  right  one  show's  faint,  pale  streaking.  Maximum 
circumference  of  head  fifty-two  and  a  half  centimetres.  No  indentation  or 
peculiarity  about  head,  barring  a  slight  frontal  prominence  of  the  hydro- 
cephalic type. 

Various  efforts  at  relief  had  failed.  Medication  effected  nothing  and 
counter-irritation  was  unavailing.  Whether  the  primary  trouble  was  a  tuber- 
cular meningitis  could  not  be  definitely  determined.  But  in  view  of  the  evi- 
dence of  increased  intracranial  pressure  it  was  decided  to  try  surgical  measures. 


CENTRAL   NERVOUS   SYSTEM.  99 

Operation  by  Dr.  Maddren,  April  29.  The  boy  was  comatose  at  this 
time  and  fast  approaching  the  end.  The  usual  preparatory  measures  and 
antiseptic  precautions  were  of  course  practised.  A  circular  flap  was  made 
with  base  upward  and  apex  just  over  the  foramen  magnum.  In  this  way  the 
field  is  clear  to  cut  through  to  the  foramen  (as  has  been  done),  and  yet  the 
larger  occipital  arteries  are  avoided.  There  was  no  great  amount  of  hemor- 
rhage ;  some  spurting  vessels  were  caught  up,  but  no  ligatures  were  needed. 

On  second  removal  of  trephine  there  was  a  rush  of  clear  fluid  from  upper 
part  of  trephine  groove.  A  considerable  quantity  of  fluid  promptly  flowed 
off,  though  only  enough  was  caught  for  a  bacteriological  examination.*  The 
current  soon  took  on  a  pulsatory  character.  A  somewhat  freer  slit  was  made 
in  the  dura.  The  button  was  also  pried  up  sufficiently  to  run  the  rongeur  under 
and  chip  out  a  small  tongue  of  bone  as  a  guarantee  of  more  prolonged  drainage. 

A  few  strands  of  waxed  silk  were  laid  across  the  little  bone-opening  and 
brought  out  beneath  the  flap  for  a  drain.  Later,  it  was  necessary  to  insert  a 
tube  instead,  as  the  flap  pressed  down  so  tightly. 

At  the  moment  of  first  relief  of  tension  the  patient's  condition  became  bad, 
but  the  usual  restorative  methods  soon  improved  him.  Only  about  a  drachm 
of  chloroform  was  used  altogether.  On  coming  out  from  the  ansesthetic  he 
was  brighter  and  in  better  shape  than  at  the  start.  By  evening  he  revived 
considerably,  said  "mamma,"  asked  for  a  "drink  of  water,"  and  showed 
more  consciousness  than  for  forty-eight  hours  previously. 

The  temperature  was  not  materially  affected,  though  it  dropped  a  degree 
for  a  day  or  more.  By  the  end  of  the  second  day,  however,  the  pulse,  tem- 
perature, respiration,  and  general  condition  showed  retrogression.  Presently 
a  conjugate  deviation  of  the  eyes  developed,  convulsions  came  on,  and  the 
temperature  rose  to  105 °.     He  died  on  the  fifth  day  after  the  operation. 

Autopsy  May  4.  Skull  thin.  The  coronal  suture  separated  in  removing 
the  calvarium.  Dura  adherent.  Slight  scattered  subdural  hemorrhage  over 
occipital  region  on  right.  Venous  engorgement  of  posterior  portion  of  both 
hemispheres.  Partly  organized  greenish-yellow  pus  between  the  largest  two 
vertex  veins  on  the  right,  just  at  their  entrance  into  the  long  sinus.  This  ex- 
tended for  an  inch  or  more  antero-posteriorly, — in  part  beyond  the  said  veins. 
This  was  over  the  paracentral  lobule,  and  had  doubtless  caused  the  weakness 
of  the  left  leg.    - 

The  chiasm  was  embedded  in  similar  greenish-yellow  gelatiniform  mate- 
rial, which  extended  posteriorly  to  middle  of  pons.     Sylvians  apparently  free. 

*  This  fluid  was  examined  by  Dr.  Ezra  H.  Wilson,  of  the  Hoagland  Labor- 
atory. He  reports  the  absence  of  all  germs,  as  shown  both  by  cultures  and 
by  injections  in  guinea-pigs. 


IOO  CENTRAL   NERVOUS   SYSTEM. 

There  was  also  a  fine  line  of  purulent  material  beneath  arachnoid  along  the 
hippocampal  fissure  on  either  side. 

The  lateral  ventricles  were  much  enlarged,  but  contained  only  about  an 
ounce  of  tinged  fluid.  Galen's  vein  was  free  except  for  post-mortem  clot. 
Foramen  of  Munro  open  ;  aqueduct  of  Sylvius  of  large  size  ;  metapore  also 
unobstructed. 

There  was  an  isolated  tubercle  *  about  the  size  of  a  small  pea  embedded  in 
floor  of  fourth  ventricle  at  about  middle  point  on  the  right. 

The  intention  in  this  case  was  to  open  through  the  foramen  of  Magendie — 
if  found  closed — into  the  fourth  ventricle,  and  in  this  way  drain  off  the  internal 
hydrocephalus.  But  by  finding  free  fluid  sooner  our  purpose  of  relieving 
pressure  was  accomplished,  and  we  therefore  desisted  from  further  interference. 
It  was  clearly,  and  as  the  autopsy  proved,  not  a  case  of  central  but  of  arach- 
noidal retention.  The  basal  lymph-cisterns  (in  particular  the  cisterna  magna 
cerebello-oblongata)  were  directly  tapped.  This  point  is  excellently  situated 
for  drainage,  and  with  the  least  possible  chance  of  infection  from  without. 

Operative  relief  of  this  particular  kind  is  one  step  in  the  right  direction.  It 
relieves  pressure.  But  where  the  trouble  is  tubercular  it  cannot  be  classed  as 
a  radical  measure.  Even  in  the  present  case,  however,  it  prolonged  life  for 
several  days,  which,  in  our  experience,  is  more  than  can  fairly  be  claimed  for 
any  other  plan  of  treatment  so  far  proposed. 

Essentially  similar  was  the  procedure  of  D'Argy  Power 
{Intnl.  Clinics,  October,  1895)  in  two  cases, — one  (No.  V.) 
of  tubercular  meningitis,  the  other  (No.  VI.)  of  non-tuber- 
cular ;  both,  however,  ending  fatally. 

For  a  double  reason  the  following  case  of  Eskridge's 
("  Irrigation  of  the  Posterior  Cerebral  Fossa  for  the  Relief 
of  Basilar  Meningitis,"  Jml.  N.  and  M.  Dis.,  November, 
1895)  is  worth  giving  more  fully.  It  was  that  of  a  man  of 
thirty,  "  with  the  appearance  of  one  dying  from  intracranial 
pressure."  The  trephine  "opening  was  about  on  the  level 
of  the  posterior  margin  of  the  foramen  magnum,  and  about 
three-fourths  of  an  inch  to  the  left  of  the  median  line  of 

*  In  this  Dr.  Wilson  found  plenty  of  giant-cells  and  tubercle  bacilli. 


CENTRAL   NERVOUS   SYSTEM.  IOI 

the  occipital  bone."  "A  large  amount  of  cerebro-spinal 
fluid  escaped."  "A  soft  catheter  was  passed  in  through 
the  opening  in  the  dura,  and  the  subdural  spaces  freely 
irrigated  in  all  directions  with  normal  salt  solution.  To 
the  right  of  the  median  line  the  catheter  easily  passed, 
without  obstruction,  a  distance  of  over  two  inches."  Con- 
siderable improvement.  Death  on  third  day.  Autopsy, 
"In  the  centrum  ovale  of  the  left  frontal  lobe  a  consider- 
able quantity  of  semi-fluid  blood  was  found,  which,  after 
ploughing  up  and  destroying  a  considerable  portion  of  this 
part  of  the  brain,  ruptured  into  the  lateral  ventricle  and 
filled  the  lateral  third  and  fourth  ventricles.  The  corpora 
striata  were  softened.  A  slight  hemorrhagic  extravasation 
was  found  in  the  right  frontal  lobe.  The  remainder  of  the 
brain  presented  a  normal  appearance." 

In  looking  about  for  other  possible  measures  of  relief, 
two  suggest  themselves.  One  is  by  making  openings  or 
communication  between  the  subarachnoid  space  and  the 
general  extra-spinal  resp.  extra-cranial  cellular  tissue.  But 
various  attempts  of  the  kind  have  been  tried,  and  so  far 
with  little  encouragement.  It  remains,  however,  the  real 
desideratum.  The  other  is  by  any  measure  that  shall  re- 
new or  increase  the  natural  absorbents  from  the  subarach- 
noid space.  Some  good  will  follow  spinal  gymnastics.  By 
this  is  meant  a  utilization  of  the  normal  mobility  of  the  spine, 
and  consequent  up-and-down  motion  of  the  cord  therein, 
as  well  as  by  the  attendant  increase  and  decrease  of  cerebro- 
spinal pressure.  By  curving  the  spine  anteriorly  all  its 
tissues  are  put  on  the  stretch  and  the  capacity  of  the  verte- 
bral canal  presumably  is  increased.  By  arching  backward 
(opisthotonos)  the  same  tissues  are  certainly  relaxed,  and 
the    space    of    the   vertebral   canal    materially   diminished. 


102  CENTRAL   NERVOUS   SYSTEM. 

Thus  a  considerable  pressure  can  be  exerted  towards  forcing 
open  any  outlets. 

In  patients  old  enough  to  have  sense,  this  exercise  can  be 
practised  voluntarily.  In  younger  ones  it  can  be  carried 
out  passively. 

Any  such  plan  applies,  of  course,  only  to  cases  with  free 
communication  between  the  brain-accumulation  and  the 
spinal  space.  The  good  accomplished,  however,  will  be  not 
merely  symptomatic,  but  tend  towards  radical  relief.  If 
we  can  diagnosticate  this  form,  then  a  systematic  course  of 
the  above  kind,  well  persisted  in,  gives  some  promise  of 
good,  and  is  rational. 

Perhaps  comparable  to  the  gymnastic  forcing  of  exits  is 
the  plan  of  Locatelli,  of  Milan  (v.  Arch.  f.  Pediatrics,  1886, 
p.  488).  He  exposes  the  child's  bare  occiput  to  solar  rays 
for  half  an  hour  or  so  daily.  Later,  this  method  was  advo- 
cated by  Sourma,  Deut.  Medizinal  Zeitung,  June  20,  1888 
{v.  Sajous's  "Annual,"  1889,  vol.  ii.),  who  began  with  only 
fifteen  minutes'  exposure. 

Evidently  this  acts  by  a  slow  but  powerful  expansion  of 
the  liquid.  His  procedure  might  possibly  avail  in  hydro- 
cephalus cut  off  from  the  general  subarachnoid,  while  the 
gymnastic  plan  is  limited  in  value  to  such  cases  as  are  not 
so  cut  off 


XII. 

PSEUDO-BULBAR  PARALYSIS. 

BILATERAL  APOPLEXY  OF  THE  LENTICULAR  NUCLEI, 
SIMULATING  LESION  IN  THE  FLOOR  OF  THE  FOURTH 
VENTRICLE.* 

It  has  not  been  thought  possible  as  yet  to  include  injury 
of  the  lenticular  nuclei  among  the  forms  of  brain  disease 
which  admit  of  approximate  localization.  A  limited  num- 
ber of  cases  have,  however,  accumulated  which  seem  to 
indicate  that  an  insult  to  both  these  nuclei,  and  perhaps 
to  only  one,  may  produce  a  picture  of  its  own. 

Since,  however,  these  bodies  are,  from  statistics,  a  very 
frequent  seat  of  apoplexy,  and,  besides,  entirely  latent  foci 
have  been  found  in  them  at  the  autopsy,  it  is  probable  that 
the  special  symptomatology  observed  in  the  other  cases 
was  caused  not  by  the  lenticular  injury  itself  but  by  an  ex- 
tension of  it  or  its  effects  to  adjacent  parts.  Be  that  as  it 
may,  that  injury  of  these  bodies  may  produce  a  very  well- 
marked  and  peculiar  group  of  symptoms  is  shown  by  the 
following  case.  It  occurred  in  the  practice  of  Dr.  Fuller, 
and  was  seen  in  consultation  by  Dr.  McNaughton.     The 


*  Reprinted,  with  some  emendations,  from  a  paper  read  before  the  New 
York  Neurological  Society,  October  7,  1884,  and,  conjointly  with  the  late 
Dr.  S.  E.  Fuller,  published  in  the  New  York  Medical  Record  of  November 
I,  1884. 

103 


104  CENTRAL   NERVOUS   SYSTEM. 

interest  of  the  case  was  fully  recognized,  and  pains  were 
taken  to  observe  all  symptoms.  The  clinical  history  is 
furnished  by  Dr.  Fuller ;  the  results  of  the  autopsy  and  the 
appended  remarks  are  by  Dr.  Browning. 

A  lady,  M.  J.,  aged  sixty  years,  complained  one  day,  while 
sewing,  of  sudden  numbness  and  tingling  in  the  left  foot 
and  ankle.  Rubbing  gave  relief,  and  it  passed  off  without 
any  physician  being  called.  In  fact,  this  was  very  likely  a 
local  matter.  Eleven  months  after,  she  was  one  evening 
attacked  with  a  feeling  of  numbness  in  the  tongue  and  pe- 
culiar sensations  in  the  left  side  of  the  body.  There  was 
no  aphasia  nor  loss  of  consciousness,  and  she  was  perfectly 
able  to  describe  her  own  feelings.  The  most  important 
objective  symptom  was  a  left  hemiparesis.  The  motor 
weakness  disappeared  entirely  in  about  two  weeks.  The 
present  attack  occurred  without  premonitions  five  months 
and  a  half  later.  It  came  on  about  four  p.m.,  July  16,  1884, 
while  in  the  bath-room.  She  is  said  to  have  called  out  to 
a  lady  in  the  next  room,  saying  she  was  very  dizzy  and  had 
pain  in  her  head  ;  the  lady  helped  her  to  bed.  There 
seemed  to  have  been  no  loss  of  consciousness  on  the  pa- 
tient's part. 

Upon  my  arrival  she  was  speechless,  and  remained  so. 
It  was  only  possible  for  her  to  make  an  expiratory  guttural 
sound.  Having  been  paralyzed  before,  she  immediately 
proceeded  to  show  me  that  it  was  not  the  same  by  raising 
first  the  right  arm  and  leg  and  then  the  left.  The  lips, 
tongue,  and  muscles  of  deglutition  were  paralyzed  ;  the 
saliva  flowed  from  whichever  angle  of  the  mouth  was  low- 
ermost ;  the  upper  portion  of  the  facial  nerve  was  function- 
ally intact,  and  the  pupils  reacted  normally.  She  could 
not  open  her  jaws,  or  only  to  the  slightest  extent.     The 


CENTRAL   NERVOUS   SYSTEM.  105 

lower  jaw  could  be  readily  depressed  with  the  finger,  but 
on  attempting  to  swab  out  collecting  mucus  from  the  oral 
cavity  and  throat — as  was  often  necessary — the  jaws  would 
close  and  press  on  whatever  had  been  introduced  into  the 
mouth,  despite  the  strongest  desire  of  the  patient  to  keep 
them  open.  The  nurse  had  to  be  instructed,  before 
cleansing  the  mouth,  to  wrap  a  blade  in  soft  material  and 
place  it  edgeways,  so  as  to  keep  the  jaws  apart  until  the 
little  procedure  was  finished.  This  symptom  persisted 
during  the  conscious  life  of  the  patient.  The  tongue  was 
quite  motionless. 

The  urine  had  been  examined  some  time  previously  and 
found  free  from  albumin.  Immediately  subsequent  to  this 
attack  there  was  an  enormously  increased  flow  of  urine. 
In  the  first  three  hours  she  passed  water  three  times. 
Though  not  measured,  it  was  estimated  by  the  attendants 
to  have  been  a  quart  each  time.  In  this  urine  there  was 
about  twenty  vol.  per  cent,  of  albumin  and  once  a  trace 
of  sugar  with  Fehling's  test.  Within  twenty-four  hours  the 
quantity  of  urine  returned  to  normal.  Albumin  persisted 
in  it,  for  a  time  at  least.  She  snored  very  loudly  after  the 
attack,  though  not  doing  so  previously.  There  was  no 
trouble  from  the  soft  palate  when  awake,  although  it  hung 
in  a  paralyzed  condition. 

So  long  as  she  remained  conscious — i.e.,  for  the  first 
five  days — she  always  gave  notice  of  a  desire  to  defecate 
or  urinate  ;  no  incontinence  whatever.  During  the  same 
period  she  would  often  motion  for  spectacles,  paper,  and 
pencil,  indicating  that  the  latter  be  first  moistened  in  the 
mouth.  She  would  then  communicate  by  writing  her 
questions,  and  showed  the  full  possession  of  her  mental 
faculties.      This  was   further   shown    by   her   remembering 


106  CENTRAL   NERVOUS   SYSTEM. 

when  medicine  was  due  (given  per  rectum  and  hypodermi- 
cally),  by  directing  attention  when  a  sample  of  urine  had 
been  forgotten,  and  in  a  variety  of  other  ways, — e.g.,  curi- 
osity as  to  the  nature  and  cause  of  her  own  condition.  She 
would,  however,  cry  rather  easily,  the  tears  then  running 
silently  down  over  the  cheeks.  This  could  hardly  be 
wondered  at  or  considered  as  loss  of  control  over  the 
feelings. 

It  is  very  doubtful  if  she  succeeded  in  swallowing  any- 
thing, though  she  tried  hard  to  do  so.  She  was  success- 
fully nourished  with  peptonized  milk,  etc.,  per  rectum. 

The  sterno-cleido  and  other  large  neck  muscles  did  not 
appear  to  be  affected.  The  sense  of  hearing  remained 
good,  and,  in  fact,  no  anaesthesia  of  any  part  of  the  body 
was  discovered. 

The  pulse,  respiration,  and  temperature  showed  no  dis- 
turbance to  within  forty-eight  hours  of  death.  At  this 
time,  after  some  extra  exertion  on  her  part,  she  gradually 
sank  into  a  stupor.  Some  twelve  hours  before  the  end 
she  became  very  much  flushed  and  hot  to  the  touch  over 
the  whole  body.  This  afterwards  gave  place  to  a  kind  of 
collapse.      Death  on  the  morning  of  July  23. 

Post-mortem  in  the  afternoon,  with  the  assistance  of  Drs. 
Fuller  and  McNaughton.  The  autopsy  being  permitted 
only  on  condition  that  nothing  whatever  be  carried  away, 
it  was  impossible  to  make  a  minute  examination  of  any  of 
the  parts,  yet  this  could  not  have  added  very  materially  to 
the  exactness  of  the  present  case.  Only  the  brain  was  re- 
moved, including  the  cord  to  opposite  the  second  cervical 
vertebra. 

The  cerebro-spinal  fluid  was  slightly  increased.  The 
vertebral  and  carotid  arteries  with  their  branches  on  the 


CENTRAL   NERVOUS   SYSTEM.  107 

base  of  the  brain  presented  numerous  patches  of  atheroma, 
but  were,  at  least  in  all  their  larger  divisions,  still  permeable. 
No  further  abnormal  appearances  on  any  portion  of  the 
surface  of  the  brain. 

The  lateral  ventricles  presented  nothing  unusual,  unless 
some  slight  adhesions  between  the  ependyma  of  the  ven- 
tricular roof  and  floor.  Laterally  in  the  brain-substance, 
on  the  two  sides  very  nearly  symmetrical,  were  two  recent 
clots.  These  were  in  the  lenticular  nuclei,  extending  into 
all  three  divisions  and  tapering  off  posteriorly. 

On  the  right  side,  in  front  of  and  external  to  the  recent 
effusion,  were  the  remains  of  what  must  have  been  a  con- 
siderable hemorrhage.  This  had  extended  antero-poste- 
riorly  along  the  external  capsule,  from  nearly  opposite  the 
front  end  of  the  ventricle  to  about  opposite  the  front  end 
of  the  recent  hemorrhage,  and  was  consequently  just  be- 
neath the  island  of  Reil.  The  claustrum  had  not  been 
broken  through  externally,  nor  the  lenticular  nucleus  at- 
tacked internally.  There  was  simply  an  oblong  space  re- 
maining, with  slightly  separated  walls  enclosing  a  little 
brownish,  thick  fluid  matter.  The  said  walls  consisted 
of  somewhat  thickened  and  discolored  tissue  without  any 
smooth  interior  surface.  Such  is,  according  to  Charcot, 
the  usual  form  and  appearance  of  old  extravasations  at 
this  point.  This  had  clearly  caused  the  former  left  hemi- 
plegia. Motor  fibres  are  not  known  to  traverse  this  tract. 
The  paralysis  must,  therefore,  have  been  caused  by  pressure 
transmitted  from  the  clot,  a  view  which  is  corroborated  by 
her  recovery. 

As  to  the  recent  extravasations,  the  same  general  de- 
scription will  apply  to  both.  Each  was  in  amount  equal, 
perhaps,  to  a  pigeon's  egg.     The  nerve-tissue  was  not  only 


108  CENTRAL   NERVOUS   SYSTEM. 

much  torn  but,  from  the  size  of  the  clot  and  its  longitudinal 
form,  also  forced  apart.  The  two  were,  from  their  appear- 
ance, of  about  the  same  date.  It  was  not  possible  in 
either  of  them  to  distinguish  any  older  or  newer  portion. 
They  were  veiy  dark,  in  part  semi-fluid,  and,  so  far  as 
color  and  character  of  the  clot  went,  at  least  one  or  two 
days  old,  perhaps  several. 

The  head  of  each  clot  was  about  opposite  the  front  end 
of  the  thalamus,  and  diminished  backward  to  nearly  oppo- 
site the  posterior  end  of  the  same.  The  main  portion  ap- 
peared to  be  wholly  in  the  lenticular  nucleus,  while  its 
posterior  prolongation  or  branches  may  have  encroached  to 
a  limited  extent  on  other  structures. 

No  further  foci  were  found  in  any  part  of  the  brain. 
The  medulla  oblongata,  pons,  etc.,  presented  no  morbid 
appearance.  Sections  through  these  parts  were  made  very 
close  together,  so  that  even  a  pin-head  clot  could  not  have 
escaped  notice.  Embolism  or  thrombosis  of  a  week's 
standing  must  have  produced  visible  softening,  so  that 
they  also  can  be  excluded.  Possibly  one  or  both  the  apo- 
plectic centres  were  at  first  much  smaller,  and  an  added 
effusion  of  blood  brought  on  the  stupor  of  the  last  few 
days,  with  the  fatal  termination.  But  there  was  nothing  in 
the  foci  to  indicate  this,  and  the  time  at  which  the  final 
condition  developed  corresponds  to  that  at  which  surround- 
ing reaction  and  the  symptoms  dependent  thereon  so  often 
occur.  Hence  the  simpler  explanation,  that  there  was  but 
one  attack  without  further  hemorrhage  on  either  side,  is  at 
the  same  time  the  more  tenable. 

The  recent  effusions  were  so  considerable  and  the  tissues 
about  them  were  so  torn  as  to  render  them  valueless  for  the 
localization  of  any  isolated  symptom.     The  interest  of  the 


CENTRAL   NERVOUS   SYSTEM.  109 

case,  however,  lies  in  the  peculiar  combination  of  symptoms. 
These  presented  a  complex  believed  to  indicate  lesion  in  a 
part  that  at  the  autopsy  was  found  intact.  To  recall  some 
of  them  :  the  paralysis  was  bilateral,  quite  symmetrical  as 
regards  both  extent  and  severity,  and  occurred  on  the  two 
sides  simultaneously.  There  was  no  loss  of  consciousness. 
Immediately  there  was  a  greatly  increased  flow  of  urine, 
containing  both  albumin  and  sugar.  There  was  also  well- 
marked  labio-glosso-pharyngeal  paralysis.  This  forms  a 
group  of  symptoms  the  cause  of  which  is  generally  assigned 
to  trouble  in  the  floor  of  the  fourth  ventricle.  Thrombosis 
or  embolism  of  a  terminal  bulbar  artery  is  credited  with 
almost  identical  consequences,  and  apoplexy  from  one  of 
the  same  vessels  may  not  appear  very  different. 

To  Joffroy  (1872)  is  given  the  credit  of  first  suggesting 
the  possible  occurrence  of  this  cerebral  form.  Then  in  1877 
Lepine  followed  with  three  actual  cases  that  he  had  col- 
lected. A  limited  number  of  observations  presenting  vari- 
ous degrees  of  similarity  to  the  present  one  are  considered 
by  Ross  in  his  work  on  "  Diseases  of  the  Nervous  System" 
(vol.  ii.  pp.  626-628  of  first  edition,  continued  in  the  sec- 
ond. Also  two  cases  of  depots  in  the  lenticular  nuclei — 
one  unilateral — are  given  by  him  in  Brain  for  July,  1882). 
From  these  he  concludes  that  destruction  of  the  lenticu- 
lar nuclei  in  the  whole  or  in  part  may  produce  nearly  if 
not  quite  all  the  symptoms  of  lesion  in  the  oblongata. 
His  cases,  however,  ran  a  slower  course,  and  were  less 
typical  of  acute  bulbar  trouble.  He  notes  that  conscious- 
ness may  not  be  lost  at  the  occurrence  of  this  accident, 
but  does  not  in  any  of  his  cases  mention  disturbance  in  the 
urinary  secretion. 

Wernike  mentions  the  occurrence  of  bulbar  symptoms 


IIO  CENTRAL  NERVOUS   SYSTEM. 

in  cerebral  disease.  He  even  cites  a  case  of  pseudo-bulbar 
paralysis  where,  however,  the  pathological  conditions  varied 
materially  from  that  under  consideration.  To  produce  this 
grouping  of  symptoms  the  lenticular  trouble  must  affect 
fibres  in  their  course  through  the  internal  capsule  from  the 
cortical  to  the  bulbar  centres,  or  else  compress  cortical 
centres  directly  opposite.  It  is  now  generally  accepted 
that  the  speech  tract,  inclusive  of  mouth-facial  and  hypo- 
glossus,  takes  a  somewhat  distinct  path  through  the  knee 
of  the  internal  capsule.  In  the  present  case  the  two  hem- 
orrhages must  have  occurred  at  the  same  time.  Although 
not  into  a  part  vitally  so  important  as  the  medulla,  yet  from 
their  size  and  after-effects  they  proved  fatal. 

Experimental  destruction  of  one  or  both  of  these  nuclei 
has  not.  established  any  facts  available  in  localization.  Fer- 
rier,  together  with  many  neurologists,  simply  believes  that 
hemiplegia  may  result  from  such  injury  when  unilateral. 
But  these  cases,  while  not  disproving,  certainly  do  not  con- 
firm this.  As  to  the  possibility  of  distinguishing  between 
these  two  (the  cerebral  and  the  bulbar)  forms,  when  acute, 
some  points  may  be  noticed.  In  the  present  case  there 
were  no  convulsions  ;  no  paralysis  below  the  throat ;  noth- 
ing unusual  in  pulse  or  respiration  ;  evidently  no  trouble 
with  the  sense  of  hearing,  but  increased  reflex  excitability 
of  the  muscles  of  the  jaw  (M.  J.  Lewis's  chin-reflex).  In 
bulbar  lesions  the  corresponding  reflexes  are,  on  the  con- 
trary, lowered,  while  the  other  symptoms,  here  absent,  occur 
with  more  or  less  frequency.  Abnormal  activity  of  the  emo- 
tional expressions  of  the  face  has  been  repeatedly  noted  in 
the  cerebral  cases. 

Such  and  similar  points  of  discrimination  would,  however, 
in  view  of  the  very  limited  number  of  known  cases  from 


CENTRAL   NERVOUS   SYSTEM.  Ill 

which  to  draw  conclusions,  hardly  warrant  confidence  in  an 
attempt  at  differential  diagnosis. 

The  occurrence  of  trismus  as  a  symptom  in  brain-lesions 
is  treated  by  W.  von  Hanger  in  the  Wien.  Med.  Wchr., 
1886,  No.  5.  Although  in  bulbar  lesions  the  correspond- 
ing reflexes  are  often  impaired,  this  does  not  always  hold, 
for  Miles  [Arch,  of  Medc,  August,  1882)  has  published  a 
case  of  hemorrhage  in  the  floor  of  the  fourth  ventricle, 
where  for  months  there  was  a  tonic  contraction  of  the 
muscles  of  mastication,  and  hence  with  increased  reflex- 
excitability  of  the  same. 

Many  writers  acknowledge  the  lack  of  distinguishing 
critera  between  the  false  and  the  true  form  of  bulbar 
paralysis.  Further,  it  has  become  evident  that,  exclusive 
of  the  asthenic  form,  in  which  no  changes  are  found,  these 
cases  of  the  pseudo-type  are  very  varied  in  their  pathology  ; 
few  are  as  simple  and  symmetrical  as  the  above. 


XIII. 


A    CASE    OF    SYMMETRICALLY    SITUATED    DOUBLE    HEMOR- 


RHAGE   OF    THE    BRAIN 


* 


Case  of  Mrs.  ,  aged  thirty-nine  years.      No  previous 

history,  except  the  existence  of  an  ulcer  of  the  left  leg,  for 
about  ten  years  off  and  on,  which  at  the  time  of  her  admis- 
sion into  the  hospital  was  the  size  of  a  man's  palm,  deep, 
and  offensive  in  odor.  The  left  leg  was  swollen  below  the 
knee,  cedematous  and  discolored  ;  foot  also  oedematous. 
Five  weeks  before  admission  into  the  hospital  the  patient 
complained  to  her  niece  of  "general  debility"  and  a 
"weakness"  especially  of  left  side  of  body,  and  also  of  a 
severe  headache  in  the  right  parietal  region,  which  was 
pretty  constant,  and  was  described  as  if  her  head  "  was  a 
hollow  iron  pot  with  some  one  hammering  inside." 

Upon  the  morning  of  her  admission  into  the  hospital 
she  got  up  feeling  pretty  well,  but  soon  began  to  drop 
things  from  her  left  hand.  Then  her  leg  began  to  get 
weak.  But  she  went  herself  and  made  application  for 
entrance  into  the  hospital.  While  being  conveyed  from 
the  central  office  (about  two  p.m.)  by  wagon,  in  getting  in 
or  out,  she  fell  once,  and  had  to  be  helped  to  her  feet,  but 
walked  fairly  well  after  that. 

When  seen  by  the  hospital  physician,  about  three  o'clock 

*  Reported  by  Mark  Manley,  A.B.,  M.D.,  late  of  the  house-staff  of  the 
King's  County  Hospital. 

112 


CENTRAL   NERVOUS   SYSTEM.  113 

p.m.,  June  12,  1896,  she  sat  up  all  right,  but  could  not  walk 
without  assistance.  There  were  muscular  twitchings  of  the 
left  arm  and  leg,  with  a  sensation  as  of  "pins  and  needles" 
in  the  left  side  of  body,  principally  in  the  arm  and  leg,  and 
especially  in  the  sole  of  the  left  foot.  The  arm  could  then 
be  used  somewhat,  but  the  leg  not  as  well.  The  left  lower 
facial  was  paretic, — as  shown  by  the  mouth  being  drawn  to 
the  right  in  smiling.  No  pupillary  changes  nor  disturbance 
of  the  motor  oculi. 

Next  seen  about  five-thirty  o'clock  p.m.  Patient  was 
then  practically  comatose.  The  left  arm  and  leg  were  in 
continual  tetanic  contraction.  There  were  some  spasmodic 
(apparently)  movements  of  the  left  hand.  The  head  and 
eyes  rotated  to  the  right.  There  was  partial  ptosis  of  right 
eye,  and  possibly  slight  ptosis  of  left  also.  Vomiting  was 
continuous  and  projectile  in  character.  Right  pupil  was 
dilated  and  external  strabismus  marked  ;  pulse  very  weak. 

The  patient  continued  in  this  condition  for  three  days 
until  she  died.  The  vomiting  stopped  after  the  first  few 
hours. 

The  autopsy  on  brain,  about  three  days  after  death, 
was  by  Dr.  Browning,  in  whose  service  the  case  oc- 
curred. The  brain  had  been  removed  shortly  after  death, 
and  thus  some  of  its  relations  had  been  rendered  uncer- 
tain. On  the  base  no  morbid  alterations  were  apparent, 
and  no  atheromatous  patches  were  to  be  seen  in  the  vessels. 
On  the  right  hemisphere  there  was  an  extensive  discolora- 
tion and  bulging  in  the  mid-  and  supra-parietal  region. 
There  was  a  couple  of  spots  here  where  the  hemorrhage 
had  ground  through  the  cortex  and  just  appeared  subpial, 
but  not  to  the  extent  of  more  than  a  considerable  external 
suffusion.     The  discolored  region  was  two  inches  or  more 


114  CENTRAL   NERVOUS   SYSTEM. 

across,  though  irregular.  It  lacked  a  scant  inch  of  reach- 
ing to  the  superior  border.  Below  it  extended  to  about 
the  level  of  the  juncture  of  the  inferior  and  middle  thirds 
of  the  central  region.  There  was  no  effusion  into  the 
ventricles.  There  was  a  vast  lesion  on  the  right.  Under 
the  motor  region  was  an  extensive  hemorrhage,  and 
chowdering  of  brain-substance.  The  bulk  of  the  hemor- 
rhage was  under  the  junction  of  the  middle  and  upper 
thirds  of  the  central  region.  The  condition  of  the  broken- 
up  tissue  suggested  previous  changes  in  it,  but  not  with 
certainty.  The  outer  portion  of  the  thalamus  was  involved 
in  the  comminution.  Anterior  to  but  continuous  with  this 
was  another  collection  of  blood  and  broken-up  tissue.  The 
lenticular  nucleus  and  structures  between  this  and  the  sur- 
face of  insula  were  pretty  well  disintegrated  and  mixed  with 
blood. 

A  large  part  of  the  caudate  nucleus  showed  grayish- 
yellow  softening,  almost  like  pus,  evidently  antedating  the 
hemorrhage.  From  about  the  anterior  extremity  of  the 
lenticular  nucleus,  and  extending  into  the  white  substance 
of  the  anterior  lobe,  was  a  collection  of  pale  yellowish 
fluid  (indefinite  cyst,  resp.  remains  of  some  former  trouble). 
This  was  immediately  adjacent  to  and  forward  of  the  ante- 
rior extremity  of  the  hemorrhage. 

On  the  opposite  or  left  side  of  the  brain  there  was  no 
visible  change  externally.  But  on  making  sections,  many 
punctiform  hemorrhages  (the  little  coagula  could  be  readily 
separated  with  the  knife)  were  found  through  the  substance 
of  the  upper  extremity  of  the  central  convolutions,  and 
even  a  little  posteriorly  to  same.  From  this  point  these 
hemorrhages  occurred  in  a  downward  and  forward  direc- 
tion, rather  crossing  to  the  front  of  the  central  convolu- 


CENTRAL   NERVOUS   SYSTEM.  115 

tions,  and  finally  ceasing  about  opposite  their  middle  point. 
Midway  in  this  tract  of  hemorrhages  was  one  larger  and 
longer  up  and  down,  amounting  in  its  whole  volume  to  the 
size  of  a  large  pea.  This  belt  of  fine  hemorrhages  on  the 
left  was  directly  opposite  to — i.e.,  corresponded  in  position 
with — the  main  volume  of  hemorrhage  on  the  right.  No 
trace  of  hemorrhage  elsewhere  on  left  side. 

In  the  cerebral  crura,  pons,  oblongata,  cerebellum,  neigh- 
boring vessels,  etc.,  no  macroscopic  change  was  found,  even 
on  section.  The  basilar  vessels,  however,  were  not  in  shape 
to  admit  of  much  examination. 

In  this  case  the  initial  symptoms  show  that  the  hemor- 
rhage started  in  the  region  where  the  greatest  effusion  was 
found.  That  in  such  a  case,  with  a  person  only  thirty-nine 
years  of  age  and  still  free  from  marked  atheroma,  we  should 
find  a  great  number  of  minute  hemorrhages,  and  at  least 
one  somewhat  larger,  and  all  these  limited  to  a  narrow  belt 
quite  symmetrical  with  the  primary  and  main  effusion,  is 
striking  in  the  extreme.  This,  doubtless,  might  have  been 
overlooked  had  we  not  been  on  the  watch  for  it.  The  fact 
that  they  were  so  numerous  showed  some  peculiar  influence 
acting  on  that  region, — an  influence  that  affected  many  or 
all  the  small  vessels. 


XIV. 

ON  DOUBLE   (SYNCHRONOUS    AND    SYMMETRICAL)   HEMOR- 
RHAGES   OF   THE    BRAIN. 

It  has  long  been  evident  that  there  were  some  points  in 
the  pathology  of  cerebral  hemorrhage  not  yet  worked  out, 
— that  the  whole  matter  was  not  summed  up  in  the  existence 
of  aneurisms,  miliary  or  otherwise.  For  a  small  proportion 
of  cases  it  is  shown,  in  another  chapter,  that  areas  of  soft- 
ening are  responsible.  Some  further  grounds  indicating 
the  incompleteness  of  this  old  explanation  of  Charcot  and 
Bouchard  are  as  follows  : 

A.  The  not  rare  onset  during  sleep,  a  time  when  certainly 
we  should  expect  least  strain  on  vessel-walls.  It  is  to  be 
remembered  that  often  a  subconjunctival  and  even  a  nasal 
hemorrhage  likewise  occurs  during  sleep,  and,  moreover, 
without  the  intervention  of  any  known  aneurism. 

B.  Constipation  and  intestinal  disorders  in  some  way 
favor  its  occurrence.  This  is  in  certain  cases  noticeable  in- 
dependent of  any  straining  at  stool.  In  the  older  literature, 
here  and  there,  is  a  case  where  apoplexy  was  brought  into 
relation  with  biliary  or  renal  calculi,  or  some  special  abdom- 
inal disturbance,  the  pain  element,  apparently,  not  being  the 
factor. 

C.  It  is  surprising  that  epileptic  convulsions  so  rarely 
cause  vascular  rupture.  Though  many  such  cases  have 
been  reported,  yet  it  still  remains  a  very  unusual  occur- 

116 


CENTRAL   NERVOUS   SYSTEM.  117 

rence,  and  is  so  regarded  by  the  authorities  (R.  Reynolds, 
Harbinson,  Niemeyer,  etc.). 

D.  The  frequent  occurrence  of  prodromata.  These  are 
largely  ignored  in  discussions,  and  are  certainly  often  absent 
or  unrecognized.  They  have  been  explained  on  the  basis 
of  a  supposed  inaugural  oozing  before  full  rupture,  but  such 
a  view  it  is  difficult  to  appreciate.  As  they  precede  the 
seizure  by  so  short  a  period,  they  cannot  well  be  attributed 
to  any  irritative  effect  of  the  aneurisms.  Perhaps  as  yet 
they  have  not  been  brought  into  sufficiently  close  relation 
to  hemorrhagic  apoplexy  by  post-mortem  proof.  In  the 
absence  of  this  last,  it  is  still  possible  that  these  were  really 
cases  of  thrombosis. 

E.  The  careful  work  of  numerous  observers  has  shown 
that  in  many  of  these  cases  no  aneurisms  can  be  found, 
and,  even  if  present,  are  not  necessarily  the  source  of  the 
effusion. 

F.  Moreover,  scattered  through  the  literature  of  the  sub- 
ject are  various  cases  of  bilateral  and  fairly  symmetrical 
hemorrhages  developing  at  nearly  or  quite  the  same  time. 
The  reason  why  more  are  not  on  record  is,  evidently,  the 
simple  one  that  nobody  has  thought  to  look  specially  for 
them,  the  effusion  on  one  side  being  usually  of  such  a 
minor  character  as  to  escape  notice.  Besides,  of  late  years 
single  lesions  chiefly  have  been  published,  as  they  better 
serve  for  purposes  of  localization. 

This  last  point  (F)  carries  with  it  a  possible  solution  of 
the  whole  query. 

The  term  "symmetrical"  is  here  used  to  indicate  the 
point  of  departure  of  the  bleeding,  and  not  necessarily  its 
size  or  shape.  Inasmuch  as  the  two  hemispheres  of  any 
brain  are  not  perfectly  symmetrical,  and  still  less  the  vessels 


Il8  CENTRAL   NERVOUS   SYSTEM. 

of  the  two  sides,  it  follows  that  physiologically  correspond- 
ing points  may  not  have  quite  the  same  site.  This  merely 
allows  a  little  more  latitude  in  the  interpretation  of  cases. 

So  far  as  present  argument  goes,  these  foci  may  be  either 
strictly  "synchronous"  or  immediately  consecutive  the  one 
to  the  other. 

While  it  is  not  unusual  to  find  remains  of  multiple  old 
hemorrhages  at  autopsy,  such  cases  can  hardly  be  utilized 
here.  Even  in  the  rather  frequent  cases  where  they  are 
found  symmetrical,  the  history  of  their  development  is  so 
far  lacking  that  it  is  impossible  to  say  whether  they  were 
synchronous  in  origin  or  not. 

i.   Case  of  double  lenticular  hemorrhage,  v.  supra,  p.  103. 

2.  Woman  of  twenty-one  years,  admitted  to  Kings  County 
Hospital  September  20,  1895.  Three  months  pregnant. 
Dysentery.  Very  delirious.  Later,  quiet  but  entirely  irra- 
tional. Death  in  a  day  or  two.  The  autopsy  (by  Dr.  Van 
Cott,  who  kindly  called  my  attention  to  the  matter)  showed 
"  hemorrhage  in  anterior  part  of  both  corpora  striata  and 
posterior  portion  of  right  thalamus." 

3.  Case  reported  above,  p.  112. 

4.  Andral,  Obs.  15.  Man  of  seventy-two  years.  For  some 
time  said  to  have  frequently  swooned.  The  day  before, 
the  faint  had  been  more  prolonged.  Admitted  in  pro- 
found coma.      Death,  without  change,  in  about  a  week. 

At  junction  of  posterior  and  middle  thirds  of  right  hemi- 
sphere, an  inch  below  the  superior  surface,  was  a  clot  the 
size  of  a  hazel-nut.  An  equal-sized  clot  similarly  situated 
in  left  hemisphere.  (More  fully  given  in  Wernicke,  Bd.  ii. 
p.  88.) 

5.  Charcot  and  Bouchard,  Arch,  de  Physiol.  Norm,  et 
Pathol.,  1868,  p.  644,  Case  III.  of  recent  hemorrhages. 


CENTRAL   NERVOUS   SYSTEM.  119 

Woman  of  seventy-four  years.  Apoplexy.  Coma.  Reso- 
lution of  extremities  perhaps  greater  on  right  side  than  on 
the  left,  but  without  manifest  predominance  of  the  paral- 
ysis on  either  side.  Death  same  day.  In  the  left  hemi- 
sphere a  large  effusion  had  ploughed  up  the  substance  of 
the  centrum  ovale  and  torn  the  striated  body.  Another 
effusion  a  little  less  voluminous  existed  in  the  symmetrical 
points  of  the  right  hemisphere. 

There  was  also  a  small  focus  in  the  pons  and  a  further 
one  in  the  left  cerebral  crus.  Miliary  aneurisms  in  the 
convolutions.      Kidneys  large  but  unaltered  in  structure. 

6.  Ollivier,  Gas.  hebd.,  1875  {v.  Wernicke,  vol.  ii.  p.  45). 
Man  of  seventy-five  years.  Sudden  attack.  Coma.  Death 
in  thirty-two  hours.  A  fresh  hemorrhage  in  the  centre  of 
each  thalamus  :  on  the  left,  the  size  of  a  hazel-nut ;  on  the 
right,  of  a  small  pea.  A  smaller  hemorrhage  in  the 
pons. 

7.  A.  Harbinson,  Jrnl.  Mental  Sci.,  October,  1877,  p. 
356.  Epileptic,  insane  female  of  thirty-six  years.  A 
condition  of  mental  torpor  followed  some  severe  seizures. 
Death  a  day  later.  "  Symmetrically  situated  in  each  pos- 
tero-parietal  lobule  was  an  apoplexy  the  size  of  a  walnut, 
containing  in  its  centre  several  separate  and  distinct  soft, 
recent  clots  (three  on  the  left  and  five  or  six  on  the  right), 
from  the  size  of  a  pea  to  that  of  a  cherry.  In  the  third 
left  occipital  convolution  was  another  clot,  the  size  and 
shape  of  an  almond,  splitting  up  the  white  fibres  ;  and  in 
the  second  left  temporo-sphenoidal  was  a  rather  smaller 
one."     Other  changes. 

8.  P.  Richer,  Bull.  Soc.  Anat.  de  Paris,  Fevrier,  1878,  p. 
94.  Attack  of  apoplexy  with  loss  of  consciousness.  Right 
hemiplegia  with  contractures.      Death  from  pneumonia  four 


120  CENTRAL   NERVOUS   SYSTEM. 

years  later.  Old  double  hemorrhage  in  central  part  of  each 
hemisphere.  Pediculo-frontal  section  on  left  showed  the 
striate  body,  including  lenticular  and  caudate  nuclei  and 
intervening  internal  capsule  destroyed.  On  the  other  side 
was  a  linear  hemorrhagic  focus  between  the  external  capsule 
(which  was  intact)  and  the  lenticular  nucleus. 

9.  Charcot  et  Pitres,  Arch,  de  Med.,  May,  1883,  Case  XL. 
(from  M.  H.  Blaise,  1882).  Man  of  seventy-four  years. 
Attack  with  loss  of  consciousness  for  half  an  hour.  After 
the  apoplectic  state  had  passed  no  motor  or  sensory  trouble 
could  be  made  out.  At  evening  the  next  day  he  was  car- 
ried off  by  a  pulmonary  congestion  without  having  pre- 
sented any  paralytic  phenomena. 

In  the  right  hemisphere  was  a  capillary  hemorrhage  size 
of  a  five-franc  piece,  occupying  the  upper  part  of  the 
parieto-occipital  fissure,  extending  out  a  little  on  its  supe- 
rior portion.  In  the  left  hemisphere  an  anologous  focus 
above  the  interparietal  fissure  and  in  the  posterior  middle 
of  the  superior  parietal  lobule. 

10.  L.  Lowenfeld,  "Atiologie  und  Pathogenese  der  spon- 
tanen  Hirnblutungen,"  Wiesbaden,  1886,  Case  XIV.  Man 
of  fifty-eight  years.  "  Multiple  old  cysts,  probably  in  part 
of  hemorrhagic  origin  (with  yellowish-red  pigmented  walls), 
and  fresh  foci  of  softening  in  the  insular  region  on  both 
sides  and  in  the  left  parietal  lobe."  He  gives  this  under 
"Sitz  des  Blutherdes,"  on  p.  35.  Then,  on  p.  84,  referring 
to  the  same  case,  he  says  that  in  the  wall  of  the  focus  sev- 
eral ruptured  vessels  (without  aneurisms)  were  found  that 
were  connected  with  blood-coagula. 

While  this  description  is  not  complete,  it  seems  to  indi- 
cate fresh  hemorrhages  of  the  insulae,  and  hence  symmet- 
rical. 


CENTRAL   NERVOUS    SYSTEM.  121 

ii.  Allen  Sym,  Edinburgh  Med.  Jrnl.,  November,  1890, 
pp.  468,  469.  Young  woman,  aged  twenty-two  years.  Ill 
about  ten  days  ;  bilious  vomiting,  with  unconscious  jerking 
of  limbs,  etc.,  later.  The  brain  showed  multiple  hemor- 
rhages in  the  optic  thalami,  besides  an  excess  of  fluid  in  the 
lateral  ventricles. 

12.  Heboid,  Arch.  f.  Psychiatric,  1892,  Bd.  xxiii.,  "Her- 
derkrankungen  im  Putamen  des  Linsenkernes,"  p.  451. 
His  second  case.  Widow  of  eighty-two  years.  In  the 
left  lenticular  nucleus  against  the  claustrum  was  a  hemor- 
rhagic softening,  and  the  same  in  less  extent  on  the  other 
side. 

13.  Eskridge's  case,  v.  supra,  p.  101. 

Perhaps  a  peculiar  observation  of  C.  K.  Mills  (Phi/a. 
Med.  Times,  1879,  vol.  ix.  p.  269)  belongs  here:  "In  re- 
gard to  the  occurrence  of  lesions  in  both  corpora  striata,  I 
might  say  that  I  have  several  times  seen  cysts  or  softening 
in  one  of  the  basal  ganglia,  apparently  formed  subsequently 
to  a  lesion  of  the  corresponding  body  on  the  other  side  of 
the  brain." 

And  very  striking  are  the  rare  cases  of  symmetrical 
porencephalic  defect  Audry  {Rev.  de  Medc,  1888,  pp. 
462  and  553)  notes  that  of  ninety-six  well-described  cases  of 
porencephalia,  thirty-two  presented  lesions  in  both  hemi- 
spheres and  were  then  always  symmetrical.  And  he  does 
not  seem  to  include  the  like  case  of  Bianchi  {v.  Am.  Jrnl. 
Nrlg.  and  PscJity.,  1884,  p.  622).  Some  of  these  were  due 
to  other  causes,  as  specific  arteritis,  emboli,  etc. 

The  number  of  cases  here  presented  may  be  small,  yet 
is  sufficient  to  bring  up  certain  queries  and  considerations. 

1.  Are  these  really  symmetrical? 

For  most  of  the  cases  this  is  so  nearly  if  not  absolutely 


122  CENTRAL   NERVOUS   SYSTEM. 

true  that  their  symmetrical  character  cannot  well  be  ques- 
tioned. 

2.  Are  these  mere  coincidences  ? 

So  far  as  those  collected  from  other  sources  go  this  might 
possibly  be  claimed,  although  any  careful  search  of  the  lit- 
erature would  give  further  support  to  the  existence  of  such 
a  class.  But  my  own  cases  have  been  sufficiently  con- 
vincing to  negative  any  such  supposition. 

Where  in  any  given  case  one  point  gives  way  there  may 
well  be  numerous  other  spots  in  the  same  brain  almost 
equally  weak.  Hence  it  might  not  be  so  surprising  to 
occasionally  meet  with  a  double  rupture.  But  it  is  remark- 
able that,  of  the  comparatively  few  cases  in  which  a  double 
effusion  develops  at  the  same  time,  such  a  considerable 
number  should  be  symmetrical.  In  view  of  the  large  ex- 
tent of  the  brain,  this  is  too  much  to  be  explained  by  any 
theory  of  chances. 

3.  Can  the  two  be  due  to  any  general  or  systemic 
state  ? 

Hardly,  for  neither,  then,  would  their  location  be  opposite 
and  symmetrical. 

Symmetrical  embolisms,  aneurisms,  and  even  tumors  of 
the  brain  have  in  rare  instances  been  observed.  But  such 
occurrences  have  no  apparent  bearing  on  the  present  ques- 
tion. More  common  are  correspondingly  situated  bilateral 
foci  of  softening.  And  as  these,  especially  involving  the 
central  ganglia,  are  occasionally  due  to  toxic  influences,  it 
is  just  possible  that  some  similar  cause  might  produce 
symmetrical  hemorrhages.  There  is,  however,  no  further 
evidence  in  support  of  such  a  supposition.  And  cases  of 
hemorrhage  following  infectious  diseases,  so  far  as  recorded, 
fail  to  show  any  such  bilateralism. 


CENTRAL   NERVOUS   SYSTEM.  1 23 

4.  Are  there  any  local  changes  or  dynamic  conditions 
that  might  suffice  for  an  explanation  ? 

The  supposition  of  a  direct  mechanical  cause  like  contre- 
coup,  or  of  double  focussing  like  the  acoustics  of  an  echo- 
chamber,  loses  force  when  we  recall  that  these  hemorrhages 
are  not  diagonally  but  directly  opposite. 

According  to  Todd  (Lond.  Med.  Gaz.,  1850,  p.  780),  it 
was  first  pointed  out  by  Bizot  that  it  was  quite  common  for 
the  arteries  of  the  brain  to  be  diseased  in  a  symmetrical 
manner.  But  if  there  is  anything  in  this,  it,  doubtless, 
refers  to  the  main  arterial  trunks,*  and  these  are  rarely  the 
seat  of  rupture.  Even  if  disease  of  these  smaller  vessels 
were  bilateral,  that  does  not  explain  why  both  should  give 
way  together. 

Possibly  the  reason  why  these  double  hemorrhages  are 
not  more  common  or  striking  is  that,  to  produce  large  effu- 
sions, some  change  in  both  the  symmetrical  vessels,  favoring 
rupture,  must  be  present. 

5.  Such  peculiar  relation  of  the  hemorrhages  may,  evi- 
dently, occur  in  any  part  of  the  cerebrum.  At  least,  these 
cases  show  no  special  preference  for  any  region, — except 
for  those  parts  more  frequently  the  site  of  hemorrhage,  five 
out  of  thirteen  involving  the  central  ganglia, — though  none 
were  in  the  cerebellum  or  pons  oblongata.  In  the  pons  it  is 
not  so  unusual  to  find  a  hemorrhage  reaching  across  to  both 
sides,  but  presumably  it  has  originated  from  a  single  point. 

*  Hadden  [Trans.  Pathol.  Soc,  London,  1884,  vol.  xxxv.  p.  73)  gives  a 
case  of  "  Symmetrical  Aneurisms  of  the  Middle  Cerebral  Arteries,"  occurring 
where  the  perforantes  are  given  off.  One  of  these  had  so  ruptured  as  to  cause 
an  effusion  into  the  substance  of  the  brain.  S.  West,  ibid.,  1889-90,  vol.  xli. 
p.  59,  gives  another  case  :  vessels  thin  ;  no  cause  for  the  aneurisms  found. 
And  W.  H.  White,  ibid.,  pp.  60-62,  gives  such  a  case,  with  symptoms  resem- 
bling cerebro-spinal  meningitis. 


124  CENTRAL   NERVOUS   SYSTEM. 

6.  There  must  be  some  common,  mutual,  or  interde- 
pendent influence  that  effects  this  symmetry.  The  only 
explanation  left  is  that  this  depends  on  nerve  action,  most 
probably  vaso-motor. 

That  there  may  be  a  bilateral  coordination  in  the  inner- 
vation of  the  brain-arteries  is  in  no  sense  strange,  though  it 
has  hardly  been  recognized  heretofore.  But  that  a  purely 
nervous  influence  plays  a  direct  part  in  the  development  of 
hemorrhagic  apoplexy  presents  a  new  principle  in  cerebral 
pathology.* 

Even  though  one  focus  is  primary  and  the  other  second- 
ary thereto,  it  still  shows  that  brain -hemorrhage  may  be 
produced  by  nervous  influence,  and  thus  quite  as  perfectly 
puts  this  factor  on  an  established  basis. 

The  full  significance  of  the  principle  can  be  worked  out 
but  slowly  ;  and  many  more  or  less  speculative  queries  im- 
mediately arise. 

That  it  indicates  the  cause  of  the  premonitory  focal 
symptoms  observed  in  some  cases  of  hemorrhage — viz.,  a 
preliminary  vascular  paralysis — is  pointed  out  in  another 
chapter. 

Where  one  of  the  effusions  remains  small,  it  may  occa- 
sionally, at  the  autopsy,  serve  to  localize  more  definitely 
the  starting-point  of  the  major  bleeding. 

An  important  question  here  is  whether  any  other  form 
of  nerve-influence  than  vaso-motor  could  accomplish  or  ex- 
plain this  occurrence  ?  This  seems  improbable,  though  it 
cannot  quite  be  denied. 

*  Lowenfeld,  /.  c,  p.  145,  says,  "  Positive  evidence  of  the  participation  of 
a  nervous  factor  [in  the  causation  of  brain-hemorrhage]  is  not  as  yet  at  hand ; 
we  are  only  in  position  to  cite  a  series  of  circumstances  that  speak  for  such  an 
influence." 


CENTRAL  NERVOUS   SYSTEM.  1 25 

In  his  recent  work  on  the  "Cerebral  Circulation"  (Lon- 
don, 1896),  L.  Hill,  after  detailing  numerous  experiments 
that  he  has  tried,  says  he  has  "  been  entirely  unable  to 
find  any  evidence  of  a  vaso-motor  supply  to  the  brain," 
p.  45.  After  considering  his  own  results  and  the  work 
of  others,  he  concludes,  p.  75  :  "The  brain  has  no  direct 
vaso-motor  mechanism,  but  its  blood-supply  can  be  con- 
trolled indirectly  by  the  vaso-motor  centre  acting  on  the 
splanchnic  area.  .  .  .  There  is,  undoubtedly,  muscular 
tissue  in  the  vessels  of  the  pia  mater,  and  it  may  well  be 
asked,  Why  is  this  muscle  present  if  it  does  not  constrict? 
Gulland  [in  a  recent  and  exhaustive  research]  has  entirely 
failed  to  demonstrate  vaso-motor  nerves  in  the  vessels  of 
the  pia.  The  muscle  is  an  elastic,  supporting  structure 
capable  of  withstanding  internal  tension,  but  as  far  as  the 
principles  of  the  cerebral  circulation  are  in  question  it  may 
otherwise  be  neglected.  If  there  is  constriction  or  dilata- 
tion of  the  cerebral  vessels,  it  is  so  small  that  it  is  overcome 
passively  by  any  rise  in  the  general  pressure." 

Such  wholesale  ignoring  of  the  muscular  structure  in  the 
brain-arteries  cannot  be  allowed  any  weight,  and  can,  cer- 
tainly, convince  no  one  who  has  ever  examined  these  ves- 
sel-walls microscopically.  Even  on  theoretical  grounds  it 
cannot  stand.  The  brain-veins  have  lost  their  muscular 
element,  owing  (as  was  pointed  out  by  the  writer  in  1884, 
and  is  amply  verified  by  the  work  of  Hill  himself)  to  the  fact 
that  they  are  merely  passive  elastic  tubes.  It  was  impos- 
sible for  the  relatively  weak  veins  to  exert  any  independent 
action  where  all  the  conditions  of  pressure  were  dictated 
by  the  stronger  arteries.  Hence  the  muscular  layer  in 
these  veins  has  completely  dropped  out.  If  now  the  arte- 
teries  were   in   their   turn    completely  secondary  to   some 


126  CENTRAL   NERVOUS   SYSTEM. 

controlling  force  outside  the  cranium  (as  Hill  contends), 
then  they  also  must  long  ere  this  have  discarded  their  mus- 
cular layer  likewise.  But  the  fact  that  the  layer  is  still 
present  proves  the  contrary.  And  if  so,  it  must  be  under 
some  control.  Because  experiments  do  or  do  not  find 
proof  of  a  vaso-motor  supply  to  the  brain  cannot,  for  an 
instant,  impugn  the  necessary  fact  that  some  control  does 
exist. 

Hill's  conclusion  has  already  been  attacked  by  Ober- 
steiner  (Wien,  1897,  v.  Neurlgc.  CentbL,  1897,  p.  356),  who 
succeeded  in  demonstrating  nerves  in  the  smaller  arteries 
of  the  pia. 

7.  How  is  this  influence  exercised  ?  Do  both  effusions 
start  together  (one  common  preceding  influence),  or  does 
one  soon  induce  the  other? 

Though  the  evidence  on  this  point  is  far  from  decisive, 
it  rather  indicates  that  the  former  supposition  is  the  cor- 
rect one. 

a.  It  is  not  necessary  that  either  be  very  large. 

b.  Yet  it  seems  to  be  only  about  the  starting-point  that 
the  two  correspond.  In  Case  III.  the  secondary  focus  re- 
mained limited  and  did  not  spread  commensurably  with  the 
first.     Certainly  any  correlation  of  the  sides  soon  ceases. 

c.  The  result  of  the  experiments  (v.  pp.  39-41)  points 
negatively  in  the  same  direction. 

d.  This  view  suffices  better  to  clear  up  the  points  raised 
at  the  outset  of  this  paper. 

8.  Is  this  influence  (vaso-motor)  sufficient  of  itself  to 
produce  leakage  or  rupture  of  brain-vessels  ?  Apparently 
it  is,  although  to  produce  any  large  effusion  there  very 
likely  must  be  some  previous  alteration  in  the  vessel-walls 
favoring  rupture. 


CENTRAL   NERVOUS   SYSTEM.  1 27 

9.  The  multiple  character  of  one  or  both  foci  in  Cases 
III.,  VII.,  and  XL,  and  perhaps  IX.  and  X.,  suggests  a 
special  form  distinct  from  the  general  run  of  apoplexies. 
It,  however,  proves  that,  occasionally  at  least,  not  some 
single  point  but  a  considerable  stretch  of  vessel  is  at  fault. 
This  serves  to  more  fully  corroborate  the  fact  that  morbid 
vaso-motor  action  is  at  the  bottom  of  the  trouble.  The 
possibility  of  an  encephalitis  hemorrhagica  is  negatived  by 
the  facts. 

The  punctate  hemorrhages  frequently  observed  after 
brain-shock  may  on  this  basis  be  a  secondary  neuro-effect 
(as  the  anaemia  has  been  shown  to  be),  and  not  a  direct  re- 
sult of  the  violence. 

The  main  principle  involved  in  the  explanation  is  just 
as  fully  demonstrated,  even  though  these  cases  prove  to 
be  but  a  special  class. 

10.  Cases  in  which  this  form  does  not  occur. 

As  a  rule,  it  does  not  in  those  due  to  rupture  of  menin- 
geal vessels,  or  to  traumatism,  whether  in  the  meninges  or 
in  the  substance  of  the  brain,  or  to  syphilitic  disease  of  the 
arteries,  or  to  softening  (absent  in  one  such  case  specially 
examined  therefor,  v.  p.  129,  Case  II.,  though  another 
case,  v.  p.  114,  makes  this  questionable). 

It  remains  to  be  determined  how  frequently,  in  the  re- 
maining ordinary  spontaneous  cases,  some  trace  of  this, 
ranging  from  simply  dilated  arteries  to  punctate  and  larger 
hemorrhages,  does  occur. 


XV. 


NOTE     ON     THE     OCCURRENCE     OF     BRAIN-HEMORRHAGE 
STARTING    IN    A    FOCUS    OF    SOFTENING. 

To  the  causes  of  cerebral  hemorrhage  should  be  added 
— more  definitely,  at  least,  than  has  yet  been  done — the 
pre-existence  of  spots  of  softening.  Presumably  these 
arrode,  or  at  least  implicate  and  weaken,  the  wall  of  some 
vessel  in  the  involved  area  ;  then  follows  the  rupture.  It 
is  not  material  to  the  pathology  of  such  a  case  whether 
some  aneurismal  dilatation  has  developed  as  an  inter- 
mediary or  not. 

A  brief  outline  of  two  cases  of  this  kind  may  suffice  to 
call  attention  to  the  matter. 

i.  The  subject  was  a  man  thirty-seven  years  of  age,  just 
recovering  from  some  ill-defined  trouble.  Severe  apoplectic 
seizure.  Death  within  twenty-four  hours.  Autopsy  in 
December,  1888,  with  Dr.  McNaughton  and  the  late  Dr. 
Fuller. 

There  was  a  large  hemorrhage  starting  from  a  small  area 
of  softening  to  the  outer  side  of  the  left  post-cornu.  This 
had  not  chowdered  the  brain-substance,  but  promptly 
broken  into  the  horn.  Owing  to  this  ready  outlet  into  the 
ventricle  the  antecedent  softening  was,  in  this  case,  practi- 
cally undisturbed,  and  hence  unmistakable.  It  was  made 
up  of  a  diffluent,  brownish  material,  but  slightly  mixed 
with  blood.  Had  this  been  deeper  in  the  hemisphere,  the 
128 


CENTRAL   NERVOUS   SYSTEM.  1 29 

bleeding  must  have  burrowed  and  ground  up  surrounding 
brain-substance  sufficient  to  have  obscured  the  primary 
focus. 

The  blood  had  filled  the  left  lateral,  passed  through  the 
foramen  of  Munro  to  some  extent  into  the  right  lateral,  but 
principally  by  way  of  the  third  ventricle  and  the  iter  into 
the  fourth.  From  this  it  had  oozed  out  on  either  side  sub- 
arachnoidal.    A  little  had  also  passed  out  per  metapore. 

2.  The  second  case  was  in  a  brain  that  I  examined 
through  the  courtesy  of  Dr.  Van  Cott,  in  October,  1896. 
It  was  from  a  woman  who  had  died  two  hours  after  ad- 
mission to  the  Long  Island  College  Hospital. 

There  had  been  a  most  extensive  effusion  of  blood.  It 
had  scattered  out  generally  under  the  arachnoid  of  both 
hemispheres,  but  collected  in  largest  amount  in  the  cisternae 
about  the  base.  A  careful  hunt  for  the  source  showed  that 
it  came  from  a  subpial  focus  of  softening,  about  two  centi- 
metres in  diameter,  on  the  median  surface  of  the  tip  of  the 
left  frontal  lobe.  The  pre-existing  detritus  was  unmis- 
takable, and  the  open  vessel  beside  it.  There  were  no 
hemorrhagic  specks  nor  especially  dilated  vessels  in  the 
corresponding  part  of  the  right  frontal  lobe,  though  there 
was  a  smaller  spot  of  broken-down  tissue  in  the  anterior 
part  of  the  right  insula. 

If  in  this  case  the  spot  of  softening  had  been  deeper  in 
the  hemisphere,  then  the  amount  of  brain-tissue  torn  up  in 
such  position  by  the  hemorrhage  itself  must  easily  have 
masked  previous  disintegration.  But  the  immediate  outlet, 
after  rupture  of  the  artery,  allowed  the  softened  material 
to  remain  almost  undisturbed. 

In  the  case  described  on  page  114  there  was  also  soften- 
ing of  considerable  extent,  which  may  have  been  a  factor 

9 


130  CENTRAL   NERVOUS   SYSTEM. 

in  the  occurrence  of  the  hemorrhage.  But  apparently  not 
so,  the  effusion  simply  breaking  into  this  earlier  focus  as 
the  direction  of  least  resistance. 

In  Michel's  case  (v.  p.  140,  sub  Spat-apoplexie)  a  large 
hemorrhage  was  attributed  to  softening  of  traumatic  origin. 

A  case  of  abscess  of  right  temporal  lobe,  with  subse- 
quent rupture  of  a  vessel  into  this  focus,  is  given  by  Dana 
(Jrnl.  N.  and  M.  Dis.,  July,  1889,  Case  I.)  ;  this  also  broke 
through  into  the  meninges. 

Many  cases,  in  corroboration,  could  be  collected  from 
other  observers,  but  there  is  little  occasion  for  doing  so 
here. 

The  best  evidence  of  this  cause  will  be  furnished  by 
special  cases  that  happen  to  be  located,  as  in  the  two 
given,  so  near  the  surface  as  to  break  through  without 
materially  disturbing  the  previously  softened  material,  and 
where,  at  the  same  time,  death  ensues  so  promptly  that 
secondary  changes  have  not  taken  place. 

Though  these  two  cases  were  meningeal  (resp.  ven- 
tricular), there  is,  a  priori,  no  reason  to  suppose  this  form 
more  frequently  due  to  softening  than  the  more  common 
cases  starting  about  the  basal  ganglia. 

This  etiology,  due  to  previous  softening,  may  be  more 
common  than  appears.  In  most  cases  of  brain-hemorrhage 
the  torn-up  and  disintegrated  tissues  about  the  starting- 
point  of  the  effusion  make  it  impossible  to  say  whether 
there  was  any  preceding  spot  of  necrosis  or  not.  In  doubt, 
it  is  classed  under  the  more  conservative  head.  A  careful 
scrutiny  with  regard  to  this  point,  eventually  with  the  help 
of  an  histological  examination,  can  alone  decide  the  fre- 
quency of  this  factor.  From  my  experience  it  cannot  be 
so  exceedingly  rare. 


XVI. 

CASES  OF  APOPLEXY  FOLLOWING  SOME    TIME  AFTER  ACCI- 
DENTS   (DELAYED  TRAUMATIC  HEMIPLEGIA*). 

It  may  be  as  well  to  begin  with  the  facts  that  I  have  to 
offer,  and  discuss  them  briefly  afterwards.  The  details  are 
given  not  from  any  intrinsic  interest  but  to  establish  the 
character  of  the  cases. 

CASE   I. 

Sarah  C,  eleven  years  old,  seen  in  the  summer  of  1895. 
When  fifteen  months  old  she  fell,  with  her  mother,  from 
the  gang-plank  of  a  steamer  in  landing  at  one  of  our  inland 
lakes,  but  was  rescued  without  injury  so  far  as  known. 
This  occurred  the  last  of  August, — i.e.,  in  the  warm  season. 
Three  weeks  later  she  suffered  a  right  hemiplegia  (called 
"sudden"  by  the  mother).  This  began  of  a  Sunday  morn- 
ing. She  first  screamed  ;  then  vomited  (curdled  milk  only). 
A  sister  (then  ten  years  old)  says  she  immediately  noticed 
that  Sarah  did  not  use  her  right  side  as  well ;  but  it  was 
not  until  evening  that  the  hemiplegia  was  certified  by  a 
physician.  During  that  first  day  she  was  sleepy  and  cried 
some,  but  was  not  strictly  unconscious.  It  was  some  three 
weeks  before  she  sat  up  again. 

She  began  to  talk  when  eight  months  old.  After  this 
attack  she  did  not  try  to  do  so  for  three  months.      From 

*  Read  in  part  before  the  "New  York  State  Association  of  Railway  Sur- 
geons," at  its  sixth  annual  meeting,  November  17,  1896. 

131 


132  CENTRAL   NERVOUS   SYSTEM. 

that  time  on  she  spoke  as  readily  as  when  she  left  off,  and 
at  present  talks  perfectly  well. 

At  first,  sensation  was  lost  on  the  right  side,  as  shown 
by  burning  her  hand  badly  without  appreciating  it. 

When  she  began  to  sit  up  there  developed  a  twitching 
of  the  right  side  of  the  face.  This  part  presently  became 
perceptibly  drawn,  and  remained  so  for  a  couple  of  years. 
No  real  paresis  of  the  face  now  remains,  though  at  times  it 
seems  to  lag  on  the  right. 

Some  five  years  ago  she  had  the  last  of  a  series  of  pecu- 
liar attacks,  evidently  epileptic  in  character.  In  these  she 
would  start  to  run  backward  and  then  turn  around.  In  the 
last  one  she  fell  backward  down-stairs  and  sprained  her  wrist. 
Even  now  any  sudden  noise  may  start  her  to  run  forward. 

She  is  a  large-framed,  well-nourished,  bright-appearing 
girl.  Weight,  ninety  pounds.  No  cardiac  murmur.  Right 
hand  and  arm  are  smaller,  softer,  and  paler  than  the  left. 
No  real  atrophy  of  muscles  of  right  fore  or  upper  arm, 
only  the  bones  are  smaller.  This  hand  keeps  in  partial 
flexion,  much  like  an  obstetrical  paralysis.  Grip,  1.  31,  r.  o 
(partly  due  to  flexion,  with  no  power  in  the  extensors). 
Contact-sensation  over  right  hand  is  very  much  reduced, 
though  when  perceived  it  is  correctly  located.  Slight  re- 
duction of  contact-sensation  over  right  lower  cheek  border. 

Methemiplegic  movements  on  yawning  and  stretching, 
and  of  the  right  arm  when  squeezing  with  the  left  hand. 
Also  on  waking  mornings  she  may  put  both  hands  over 
her  head,  a  thing  not  possible  voluntarily. 

The  walk  shows  a  slight  hitch  and  throw  on  the  right. 
She  sits  in  one  uneasy  twist  if  talking  or  at  all  excited,  and 
is  such  a  restless  body  that  any  thorough  examination  is 
difficult. 


CENTRAL   NERVOUS   SYSTEM. 


133 


Pupils  are  equal,  and  each  reacts  well  from  all  parts  of 
retina  (to  ophthalmoscopic  illumination).  The  hemiopic 
defect  in  the  vision  of  each  eye  is  fairly  homonymous,  as 
shown  by  the  accompanying  chart. 


Outline  of  visual  field  in  Case  I. 

Though  taste  and  smell  were  asserted  to  be  intact,  the 
latter  proved  to  be  somewhat  impaired  on  the  left. 

Hearing  has  long  been  supposed  to  be  poorer  on  the 
left,  but  testing  shows  first  one  ear  better,  then  the  other. 

Does  fairly  well  in  school  ;  is  backward  in  mathematics 
if  in  anything.  Whistles  and  loves  music.  "Sure  to  see 
the  funny  side  of  everything,  and  bound  to  have  a  good 
laugh."      Again  is  rather  sober. 

CASE    II. 

Gentleman  of  forty-two  years,  referred  to  me  by  Dr.  H. 
B.  Delatour  in  February,  1896. 

Has  been  troubled  somewhat  by  asthma  all  his  life. 
Otherwise  was  perfectly  healthy  and  active  until  an  acci- 


134  CENTRAL   NERVOUS   SYSTEM. 

dent  seven  years  ago  (in  March,  1889).  At  that  time  he 
was  thrown  from  a  wagon,  and  chased  the  horse  three  hun- 
dred feet  to  catch  it.  Immediately  on  securing  the  animal 
he  experienced  a  pain  in  the  left  occipital  region.  This 
kept  up,  but  as  he  suffered  no  other  inconvenience  he  still 
went  about  as  usual.  Just  a  week  after  the  accident  he 
was  taken  with  the  attack  which  disabled  him.  One  morn- 
ing, while  waiting  at  a  railroad  station,  he  first  noticed 
some  trouble  in  speech, — could  not  say  what  he  wanted 
to,  neither  could  he  write  it.  He  got  back  home  by  train, 
recalls  going  into  the  house,  but  has  no  recollection  further. 
In  fact,  the  rest  of  that  day  he  sat  around  and  could  say 
only  "Don't  know,"  or  some  such  phrase.  That  night  on 
retiring,  and  before  he  was  in  bed,  he  was  heard  to  fall, 
and  was  found  fully  unconscious,  breathing  heavily  (was 
even  thought  to  be  dead).  His  physician,  Dr.  J.  W. 
Koontz,  of  Mount  Jackson,  Virginia,  writes  me  that  he 
found  him  suffering  from  a  slight  paralysis  of  the  right  side, 
with  aphasia. — "  I  do  not  remember  whether  he  suffered 
from  nausea  or  not,  but  I  rather  think  he  did."  "  He  re- 
mained unconscious  for  three  weeks."  When  finally  he 
came  to  he  could  not  talk, — "  a  word  or  two  at  a  time 
only."  The  face  was  also  drawn  to  the  left,  as  it  is  slightly 
even  yet.  After  a  month  or  so  he  was  able  to  get  about  a 
little,  dragging  his  right  foot.  It  is  claimed  that  ever  since 
then  he  has  been  completely  anaesthetic  over  left  side  of 
head,  including  mouth  and  tongue  (cannot  feel  food  on 
that  side).  But  from  the  top  of  the  neck  down  the  anaes- 
thesia is  on  the  right  side,  and  not  quite  so  absolute. 

During  the  hot  weather  last  summer  (1895)  his  left 
eye  turned  outward,  the  lid  falling  completely  down.  At 
present  this   is   partly  voluntary  to  cut  off  diplopia.      He 


CENTRAL   NERVOUS   SYSTEM.  1 35 

cannot  open  that  eye  as  widely  as  the  other,  though  the 
degree  of  ptosis  varies.  Previously  there  was  none  of  this 
eye-trouble. 

Formerly  weighed  two  hundred  and  six  pounds ;  about 
five  years  ago,  one  hundred  and  eighty  ;  now,  one  hundred 
and  sixty.  He  has  never  weighed  as  much  since  the  shock, 
but  the  total  loss  has  been  gradual.  Very  constipated 
since  this  trouble. 

Heart-sounds  clear.  No  bruit  about  head.  Pulse  varies 
on  different  days  from  64  to  108  (the  last  following  an 
attack  of  asthma). 

Right  hand  very  cool,  a  little  puffy,  at  times  trembly ; 
fingers  nearly  straight.  Grip,  r.  59,  I.  88.  No  increase  of 
wrist  or  arm  reflexes  on  either  side.  Still  writes  exclu- 
sively with  his  right  hand. 

Pain-sense  over  right  hand  and  thigh  much  impaired, 
somewhat  also  over  calf.  Touch  (brush-contact,  as  also 
differentiation  of  two  points)  is  very  greatly  reduced  over 
the  right  side  ;  localization  fair  when  once  perceived. 

While  tests  of  cutaneous  sensation  over  head  give  incon- 
stant results,  the  following  may  pass  as  an  average.  Con- 
tact of  fine  brush  against  left  half  of  face  (including  nose, 
chin,  cheek,  and  fronto-temporal  region)  is  not  quite  as 
easily  detected  as  on  the  right.  Esthesiometer  over  right 
facial  region  gave  three  centimetres  ;  over  left,  six  centi- 
metres ;  localization  in  these  areas  is  fair  but  not  perfect. 
Pain-sense  (pricking  or  electric  brush)  somewhat  acuter 
over  right  side  of  head,  though  weaker  even  there.  But 
temperature  differences,  apparently,  were  better  perceived 
over  the  left  side  of  head. 

A  very  small  spot  on  the  cranium,  an  inch  or  so  above 
and  slightly  back  of  exit  of  left  occipital  nerve,  is  decidedly 


136 


CENTRAL   NERVOUS   SYSTEM. 


tender  to  pressure  and  over-sensitive  to  the  current.  This 
is  where  he  has  had  the  pain  since  the  accident,  sometimes 
for  months  continuously,  and,  if  anything,  worse  by  day. 
Exit  of  occipitals  not  tender.  One  large,  flat  nuchal  gland 
on  the  left. 

In  walking  he  uses  a  stick,  and  hitches  or  drags  the 
right  leg  some, — literally  "puts  best  foot  forward,"  espe- 
cially in  going  up-stairs.  Cramps  in  hip  and  leg  on  right 
are  common  after  sitting.  There  is,  on  the  right,  a  slight 
knee-jerk  from  the  tendon,  but  stronger  from  the  patella. 
Left  is  variable,  though  usually  weak. 

Visual  fields  were  as  shown  on  the  following  chart.      For 


L.J?. 


Visual  field  in  Case  II.     Dotted  line  indicates  limit  for  red. 


the  various  colors  perception  was  reduced  correspondingly 
with  that  for  red.  This  concentric  limitation  suggests  that 
the  visual  deficiency  here  might  be  functional  rather  than 
definitely  organic.  Left  pupil  is  a  trifle  wider  than  right. 
Left  eye  drops  outward,  and  is  poorly  mobile, — upward 


CENTRAL   NERVOUS   SYSTEM.  1 37 

to  horizontal  only,  and  inward  but  little  beyond  the  middle 
line  (doubtless  paretic  oculo-motor). 

Watch  heard  on  the  right  at  three  inches,  on  the  left  at 
three  feet.  Cannot  hear  slight  sounds,  or  else  fails  to  heed 
them. 

Laughs  or  cries  over-easily.  Catches  a  joke  quickly. 
Has  much  trouble  in  talking,  the  effort  at  times  getting 
him  into  a  general  tremor.  Often  uses  wrong  word,  and 
then  tries  to  correct  it,  gesticulating  frantically  with  his 
left  hand.  Has  great  difficulty  in  writing  a  letter,  and 
always  makes  some  mistakes.  In  writing  from  dictation 
often  has  to  have  it  spelled.  Can  repeat  after  a  person 
much  better,  though  not  perfectly.  Has  to  hurry  when 
he  wants  to  urinate  or  do  anything. 

On  September  12,  1896,  Dr.  Delatour  trephined  at  the 
point  of  chief  complaint.  There  appeared  indications  of 
a  former  fracture  reaching  forward  and  upward  (slight 
depression  in  bone,  and  firm  adhesion  of  pericranium  and 
dura  at  the  spot  and  in  the  direction  indicated).  The  pia 
was  free  in  all  directions.  Brain-surface  grayish  rather 
than  pink,  pulsating  some. 

Since  this  he  has  better  control  of  muscles  about  the  left 
eye,  but  otherwise  there  is  little  change. 

In  each  of  these  cases  the  element  of  suits  for  damage 
was  completely  absent,  and  the  evidence  of  organic  mis- 
chief positive,  so  far  as  it  can  be  without  autopsy.  They 
were  cranial  and  not  spinal  cases.  Aside  from  the  brain- 
injury,  each  of  these  patients  was  still  possessed  of  an  ex- 
cellent physique,  still  in  the  enjoyment  of  good  health, 
and,  though  somewhat  mobile  of  temperament,  still  cheer- 
ful as  a  rule.  At  the  time  of  the  accident  neither  had 
reached  the  favorite  age  for  apoplexy. 


138  CENTRAL   NERVOUS   SYSTEM. 

It  may  be  taken  for  granted  that  with  such  histories, 
relating  to  persons  in  youth  or  before  any  decline,  no  one 
will  question  the  relation  of  cause  and  effect, — i.e.,  that  the 
accident  induced  the  brain-trouble. 

CASE   III. 

For  the  following  case  I  am  indebted  to  Dr.  Philleo,  of 
Brooklyn.  The  patient  was  a  paver,  over  forty  years  of 
age,  who  had  suffered  a  blow  or  fall  on  the  head.  He  was 
brought  to  the  hospital  unconscious,  but  soon  recovered. 
Discharged  two  and  a  half  days  later,  apparently  all  right. 
He  went  back  to  his  occupation  and  continued  work  for  a 
whole  week  without  any  known  or  manifest  symptoms. 
But  eleven  days  after  the  accident  he  was  brought  in 
again  and  died  promptly.  The  post-mortem  examination 
revealed  a  fracture  of  the  base  that  dated  back  to  the  time 
of  the  accident. 

The  following  somewhat  similar  observations  help  to  de- 
termine more  definitely  upon  what  pathological  basis  such 
cases  depend. 

Hilton  ("Rest  and  Pain,"  New  York,  1879,  pp.  16,  17) 
says  :  "  Some  time  since  I  was  requested  to  see  a  gentleman 
in  the  country  who,  coming  home  from  hunting,  was  thrown 
from  his  horse  and  got  his  foot  entangled  in  the  stirrup. 
In  his  fall  he  struck  the  back  part  of  his  head.  After  a 
time  his  horse  was  stopped  ;  he  disentangled  his  foot  from 
the  stirrup,  and,  expressing  himself  somewhat  confused, 
mounted  his  horse  again  and  rode  several  miles  home. 
This  gentleman  occupied  himself  as  usual  during  thirteen 
days,  occasionally  riding,  sometimes  walking,  but  more 
frequently  driving  about  the  country  in  the  pursuit  of  his 
business  and  attending  one  of  the  county  markets.      He 


CENTRAL   NERVOUS   SYSTEM.  1 39 

then  became  the  patient  of  the  surgeon  who  requested  me 
to  see  him.  At  the  time  I  saw  him  he  was  suffering  from 
some  indications  of  paralysis  dependent  on  injury  at  the 
base  of  the  skull  or  high  up  in  the  cervical  region.  This 
patient  subsequently  died,  and  upon  examining  his  skull  it 
was  found  that  he  had  been  the  subject  of  a  fracture  of  its 
base  ;  yet  he  pursued  his  ordinary  avocations  for  thirteen 
days  without  the  slightest  evidence  of  any  cerebral  or  brain 
lesion,  complaining  only  of  headache  and  some  febrile  con- 
dition." 

Ewen,  Brit.  Med.JmL,  1 888,  i.  p.  899.  A  boy  of  ten  years 
received  a  blow  on  the  head.  Not  until  sixty  hours  later 
did  he  complain  of  severe  headache.  Soon  passed  into 
coma  with  general  relaxation.  Death  seventy-two  hours 
after  injury.  Autopsy  showed  a  thick  clot,  size  of  palm  of 
hand,  on  the  left  side  between  dura  and  bone. 

According  also  to  Wiessmann,  coma  may  be  exceedingly 
delayed,  one  instance  of  eleven  days  being  quoted. 

Starr  and  McBurney,  Brain,  1891.  Man  fell  from  a 
wagon.  No  loss  of  consciousness  and  no  external  wound. 
Several  hours  later  he  gradually  became  stuporous  ;  then 
unconscious  for  three  days.  Lasting  aphasia,  paralysis  of 
right  arm,  and  paresis  of  right  leg.  Partial  right  anaesthesia. 
Slight  dementia.  Trephining,  with  removal  of  a  clot.  Cure. 
This  is  attributed  to  hemorrhage  from  a  vein  of  the  pia. 

My  attention  has  been  very  kindly  called  by  Dr.  Town- 
send,  of  New  York,  to  Scudder  and  Lund's  paper  (Am. 
/ml.  Med.  Sc,  April,  1895),  giving  data  on  the  interval  of 
consciousness  between  the  occurrence  of  head-injuries  and 
the  development  of  coma  from  meningeal  hemorrhage. 

The  longest  period  in  any  of  their  collected  cases  was 
two  months  (ten  days  longer  before  coma).     This  was  in 


140  CENTRAL   NERVOUS   SYSTEM. 

Ceci's  case,  of  the  subdural  form.  In  the  extra-dural  group, 
Ransohoff's  case  showed  a  free  interval  of  eight  days.  The 
last  writer  {Annals  of  Surgery,  1890,  vol.  ii.  p.  116)  also 
discusses  this  point. 

It  appears  that  in  about  one-half  of  such  cases  there  is 
some  interval  of  consciousness  after  the  injury. 

Somewhat  different  is  the  recent  case  of  E.  Michel 
("  Ein  Beitrag  zur  Frage  von  der  sogenannten  traumati- 
schen  Spatapoplexie,"  Wiener  klin.  Wchr.,  1896,  No.  35, 
v.  Brln.  kin.   Wchr.,  1897,  i.  p.  16). 

"A  man  was  injured  by  the  falling  of  an  iron  bar,  but 
showed  no  commotio  cerebri.  For  a  week  he  continued 
feeling  comparatively  well,  except  for  some  headache. 
Then  severe  brain-symptoms  developed  and  he  died.  Au- 
topsy showed  :  suffusion  under  the  scalp  on  the  right,  but 
cranial  bones  intact ;  hemorrhage  between  dura  and  pia, 
and  into  the  pia  on  the  right,  more  posteriorly  ;  blood-filled 
cavities  in  both  occipital  lobes,  on  the  right  to  the  outer 
side  of  and  breaking  into  the  ventricle  ;  ventricle  full  of 
blood  ;  numerous  small  hemorrhages  in  the  vicinity  of  the 
blood-cavities  and  in  the  ependyma  of  the  lateral  ventri- 
cles. Apparently  these  small  hemorrhages  directly  caused 
by  the  injury  led  to  brain-softening,  and  in  their  further 
course  to  the  fatal  late  apoplexy." 

These  various  cases  and  citations  indicate  that  meningeal 
bleeding  (extra-  or  subdural)  is  the  most  common  cause  of 
delayed  traumatic  apoplexy.  The  reason  for  the  striking 
delay  in  the  development  of  symptoms  is  not  so  clear.  In 
some  cases  there  may  have  been  oozing  at  the  start  or  in 
the  interval ;  then  came  a  more  distinct  vascular  break. 
Again,  it  is  an  early  or  gradual  accumulation,  to  which  the 
brain  is  unable  longer  to  accommodate  itself. 


CENTRAL   NERVOUS   SYSTEM.  1 4 1 

There  is  a  further  group  of  cases  resembling  the  above 
in  the  delayed  development  of  paralysis,  but  without  coma. 

Armstrong.  Jrnl.  Am.  Med.  Assc,  1887,  vol.  i.  p.  679.  Ne- 
gro of  fifty-three  years.  Struck  on  left  forehead  by  a  brick. 
Scalp  wound  but  no  injury  of  bone.  "  Unconscious  for  a 
time."  Then  recovered,  except  for  a  roaring  in  his  head, 
and  wound  healed.  Right  foot  began  to  drag,  just  fifty 
days  after  accident,  and  developed  into  a  hemiplegia.  On 
trephining  over  left  motor  area  and  slightly  opening  dura, 
a  quantity  of  "dark-brown  blood"  was  evacuated.  Re- 
covery. 

He  quotes  a  case  from  Sylvestrini  (1883)  where  tempo- 
rary hemiplegia  occurred  two  months  after  an  accident,  and 
full  hemiplegia  five  months  after.      Trephining.      Death. 

Also  a  case  from  Grainger  Stewart  {Brit.  Med.  Jrnl., 
1887,  i.)  where  headache  began  two  weeks  after  accident, 
leading  to  hemiplegia.  Trephining  two  months  after. 
Death. 

Fisher,  of  New  York,  has  recorded  an  autopsy  in  which 
there  was  a  large  extra-dural  hemorrhage  that  had  existed 
for  years,  and  yet  caused  no  manifestations  even  at  its 
origin. 

Therapeutically  we  can  draw  the  lesson  that  persons 
suffering  from  violence  need  care  for  some  time.  One  in- 
dication is  for  quiet  and  sedatives.  Avoid  any  excitement, 
exertion,  or  even  mental  stimulus.  Depressants,  especially 
of  the  blood-pressure,  should  be  almost  a  routine  treat- 
ment. Bromides,  aconite,  etc.,  are  invaluable  in  warding 
off  harm.  There  is  also  a  strong  indication  for  relief  by 
trephining  in  these  late  cases,  provided  sufficient  points  for 
localization  can  be  made  out. 

Those  who  follow  practical  medical  work  must  continu- 


142  CENTRAL   NERVOUS   SYSTEM. 

ally  be  impressed  by  the  closeness  with  which  we  have  to 
correct  our  theories  to  assort  with  fact.  Therefore  the 
simple  and  honest  relation  of  selected  cases  constitutes  the 
basis  of  clinical  knowledge.  And  such  is  my  reason  for 
offering  you  this  report  of  cases,  not  in  themselves  espe- 
cially novel,  except  that  they  represent,  in  one  regard,  a 
peculiar  group,  and  one  that  a  priori  we  should  little 
expect  to  occur. 

Furthermore,  they  are  in  a  line  that  you,  gentlemen  of 
this  society,  must  have  unusually  favorable  opportunities 
of  observing. 

The  various  immediate  results  of  accidents  on  the  one 
hand,  and  the  great  group  of  late  and  indirect  results 
(classed  under  railway  spine  or  brain)  on  the  other,  are 
fully  recognized.  But  well-marked  cases  of  moderately 
delayed  results  ought  to  have  interest  not  only  in  them- 
selves, but  also  as  showing  conclusively  that  not  all  the 
evils  of  an  accident  develop  in  immediate  sequence  on  the 
event. 

P.  S. — Mention  might  here  be  made  of  some  experi- 
ments on  the  cadaver,  made  last  summer  with  Dr.  Mark 
Manley  at  the  Kings  County  Hospital.  These  were  to  de- 
termine, if  possible,  the  weak  points  in  the  dural  arteries. 
Three  times  on  two  subjects  pressure  up  to  a  hundred 
pounds  to  the  square  inch  was  tried,  and  yet  without 
much  success.  In  one  case,  where  blows  were  directed  to 
the  parietal  region  during  the  injection,  a  slight  effusion 
occurred  in  the  upper  parietal  region.  The  injections 
were  made  at  the  base  of  the  skull  by  introducing  the 
cannula  into  the  medi-dural  through  the  slit-open  external 
carotid.  No  better  result  was  obtained  in  one  trial  where 
the  calvarium  had  been  removed  from  the  opposite  side. 


XVII. 

A   CASE    SUGGESTING    MULTIPLE    SCLEROSIS,    BUT   DUE    TO 
CRANIAL   ANEURISM.* 

This  is  a  case  that  has  interested  a  number  of  medical 
men  and  been  demonstated  before  several  clinics. 

The  patient,  C.  A.,  of  German  parentage  ;  age,  twenty- 
five  years ;  height,  six  feet  one  inch  ;  was  admitted  to  the 
Kings  County  Hospital  January  12,  1895. 

At  his  occupation  as  a  brass-finisher  he  has  had  to  do 
much  lifting  of  heavy  weights, — really  had  often  to  hold 
and  stem  heavy  objects  against  the  polisher,  thus  prolonging 
the  strain. 

He  has  a  noticeably  dull  and  stupid  or  lubberly  appear- 
ance ;  his  mother  says  he  has  always  been  so,  and  very  slow 
to  learn. 

He  dates  back  his  trouble  to  four  years  ago.  It  began 
with  the  following  symptoms.  He  first  complained  of  a 
dull,  continuous  pain,  which  involved  the  whole  right  side 
of  head.  About  one  year  subsequently  he  noticed  a 
tremor  of  right  hand,  which  increased  in  severity,  compel- 
ling him  to  give  up  work.  This  was  followed  by  inability 
to  stand  erect  in  one  position  for  any  length  of  time  without 
liability  of  falling.     At  that  time  if  he  heard  a  noise  while 

*  Reported  by  Dr.  F.  E.  Lambert,  late  of  the  house- staff  of  the  Kings 
County  Hospital.  Read  before  the  Brooklyn  Society  for  Neurology,  February 
28,  1895. 

H3 


144  CENTRAL   NERVOUS   SYSTEM. 

urinating  it  would  excite  him,  causing  the  flow  of  urine  to 
suddenly  stop  ;  he  would  then  be  unable  to  urinate  for 
several  hours. 

For  the  past  year  patient  has  been  unable  to  walk  with- 
out staggering,  and  says  that  if  he  heard  any  one  behind 
him  he  would  have  to  wait  until  they  passed.  About  that 
time  nystagmus,  diplopia,  and  headache  were  troublesome. 
The  tremor  of  right  hand  had  gradually  increased  until  he 
was  unable  to  lift  a  cup  of  tea  to  the  mouth  without  spill- 
ing its  contents,  the  shaking  increasing  progressively  as  the 
hand  approached  the  mouth. 

His  present  symptoms  include  the  following.  His  right 
hand  shows  great  tremor  of  the  intention  type  on  every 
motion  and  effort,  but  is  perfectly  quiet  while  at  rest.  No 
tremor  of  left  hand,  which,  however,  in  contrast  to  the 
right,  is  of  a  remarkable  purple  color,  and  usually  cooler 
than  the  right.  The  color  and  appearance  of  right  hand  is 
normal.  There  is  no  motor  paralysis  of  either  hand,  the 
relative  power  of  the  two  being  preserved.  Arm  and  wrist 
reflexes  normal  and  alike  on  the  two  sides. 

On  February  6  it  is  noted  that  for  the  past  two  nights 
the  patient  was  awakened  by  pain  in  the  little  finger  of  the 
right  hand  ;  it  was  dull  in  character  and  lasted  about  two 
hours.  He  also  had  pain  in  the  adjoining  finger  and  the 
corresponding  finger  of  left  hand. 

It  may  be  remarked,  in  passing,  that  patient  has  a  con- 
genital and  symmetrical  deformity  of  the  little  fingers. 

When  standing  there  is  a  continual  fascicular  and  gen- 
eral trembling  of  whole  right  lower  extremity  (calf,  thigh, 
and  buttock),  which  entirely  disappears  when  lying  quietly, 
and  does  not  involve  the  left  leg,  except  by  transmission  of 
the  vibration. 


CENTRAL   NERVOUS   SYSTEM.  145 

Both  knee-jerks  present ;  left  the  stronger.  No  ankle- 
clonus.  When  standing  there  is  excessive  incurve  of  lum- 
bar spine  (lordosis).  His  gait  shows  a  peculiar  hitch  and 
faltering  of  the  right  side.  No  trophic  disturbance  noticed 
on  the  lower  extremities. 

There  is  a  paresis  of  left  lower  facial  ;  can  scowl  and 
close  upper  but  not  lower  eyelid  on  that  side.  Draws 
mouth  better  to  the  right  than  to  the  left ;  noticeable  also 
on  laughing,  and  at  times  there  is  some  twitching  in  the 
muscles  of  right  cheek.  This  condition  of  the  face,  his 
mother  says,  has  developed  within  the  past  two  years.  No- 
ticeable atrophy  of  right  half  of  tongue  anteriorly.  Tongue 
comes  out  straight,  and  palate  hangs  in  the  median  line. 
Pharyngeal  reflex  seems  absent.  In  speech  there  is  some 
thickness,  with  mechanical  hesitancy  and  catching  at  words. 

The  left  pupil  is  larger,  especially  in  twilight.  Pupillary 
reaction  is  preserved  on  each  side.  Nystagmus  of  both 
eyes,  more  when  looking  upward  or  to  either  side,  and 
some  when  looking  down.  It  is  a  vertical  nystagmus 
when  looking  upward,  but  lateral  in  all  other  positions. 
The  right  eye  tends  to  turn  a  little  out  and  upward.  He 
also  claims  to  see  better  with  left  eye.  Diplopia  most 
troublesome  in  distant  vision.  Ophthalmoscopic  examina- 
tions show  fairly  normal  conditions  ;  right  retina  pale,  disk 
distinct,  and  the  arteries  have  the  double  contour.  Veins 
full,  and  no  pulsation  observable.  Condition  of  left  retina 
similar.      Examination  disturbed  by  nystagmus. 

General  sensations  were  carefully  examined  by  Dr.  E.  P. 
Hickok,  assistant  neurologist  to  department,  who  found  no 
disturbance  whatever  as  to  contact,  localization,  or  pain- 
senses.  There  is  seborrhcea  of  scalp  and  somewhat  of  ears 
and  eyebrows. 


146  CENTRAL  NERVOUS   SYSTEM. 

In  attempting  to  make  a  diagnosis,  at  the  time,  several 
possibilities  were  considered.  Against  syphilis  was  a  de- 
cidedly negative  history,  the  absence  of  any  other  marks 
of  it,  and  the  futility  of  specific  treatment. 

The  symptoms  seemed  hardly  attributable  to  any  form  of 
brain-tumor. 

In  many  respects,  some  form  of  multiple  sclerosis  was 
thought  to  offer  a  fair  explanation  (the  tremor,  though  uni- 
lateral, nystagmus,  speech-trouble,  and  various  widely  scat- 
tered symptoms),  though  not  fully  satisfactory.  At  a  sub- 
sequent examination  the  following  points  were  elicited. 
Pulsation  of  right  side  of  neck  is  very  much  accentuated. 
This  is  distinctly  visible  below,  in  front  of  (temporal  artery), 
and  behind  the  right  ear.  Patient  complains  of  a  noise 
like  a  steam-engine  in  right  ear.  This  proves  to  antedate 
all  other  symptoms,  extending  back  six  years.  On  the 
right  side  of  neck,  in  the  notch  directly  back  of  mastoid, 
on  palpation  a  distinct  purring  sensation  is  felt  with  each 
beat,  easily  recognized  as  a  full,  strong  aneurismal  thrill. 
Mitral  sounds  normal ;  aortic  weak  and  a  slight  murmur 
with  first  beat.  A  continuous  and  very  loud  roar  (venous 
hum)  is  heard  over  the  right  clavicle.  The  whirring  noise 
from  the  mastoid  can  be  distinctly  heard  over  the  entire 
cranium  with  each  beat.  Its  character  is  almost  as  striking 
on  diagonally  opposite  parts,  over  the  malar  prominence, 
or  at  any  part  solidly  connected  with  the  skull.  Coughing 
or  sneezing  makes  him  quite  dizzy.  Hearing  is  defective, 
especially  in  right  ear.  He  fails  to  readily  discriminate 
sounds,  and  is  quite  oblivious  to  a  low  conversation.  Can 
hardly  distinguish  the  ticking  of  a  watch,  even  in  direct 
contact  with  right  ear.  Inspection  of  fauces  shows  fulness 
and  pulsation  on  the  right.     Compression  of  the  right  com- 


CENTRAL   NERVOUS   SYSTEM.  1 47 

mon  carotid  completely  stops  the  bruit,  and  almost  com- 
pletely arrests  pulsation  behind  mastoid. 

This  evidence  fully  demonstrated  the  existence  of  an 
aneurism  in  some  branch  of  the  right  carotid. 

At  first  the  external  occipital  appeared  the  most  prob- 
able seat,  as  the  palpable  bruit  is  so  far  back ;  but  the 
evident  size  of  the  dilatation,  the  fact  that  the  internal 
artery  is  the  one  commonly  involved,  that  tinnitus  was  a 
primary  symptom,  and  that  the  souffle  is  so  clearly  heard  at 
any  point  in  the  cranial  bones,  indicate  the  internal  carotid 
as  the  vessel  most  probably  affected.  Or  a  fusiform  and 
more  extensive  dilatation  may  be  present.  To  cause  all 
these  symptoms  the  aneurism  must  not  only  exert  a  direct 
pressure, — as  evidently  on  the  outgoing  hypoglossus  to  an 
extent  that  partly  cuts  the  nerve  off, — but  also  in  some 
way  involve  adjacent  intracranial  structures.  Whether  this 
latter  is  an  effect  of  the  continual  vibrations,  or  whether 
the  enlargement  pressed  directly  on  the  parts  is  fairly  an- 
swered by  the  later  course  of  the  trouble.  It  was,  at  any 
rate,  clear  that  some  effort  should  be  made  to  cure  the 
aneurism.  It  was  proposed  to  the  patient  to  tie  one  vessel 
first,  and  if  later  this  proved  insufficient,  the  other  could  be 
treated  in  like  manner. 

Dr.  A.  T.  Bristow  kindly  saw  the  patient,  coincided  in  the 
indications,  and  on  February  21  ligated  the  right  common 
carotid.  The  patient  recovered  somewhat  slowly  but  excel- 
lently from  the  operation,  and  made  uninterrupted  progress 
for  a  time.  By  February  24  several  of  the  most  prominent 
symptoms  had  almost  entirely  disappeared,  among  them 
being  the  tremor  of  right  hand,  headache,  purple  color  of 
left  hand,  the  ear-noises,  as  also  the  objective  bruit  and 
local  fulness  on  palpation. 


148  CENTRAL   NERVOUS   SYSTEM. 

Two  weeks  after  the  operation  his  condition  was  still 
better.  The  tremor  of  hand  appeared  only  on  prolonged 
extension,  and  then  even  was  but  slight.  Ordinarily  speak- 
ing, there  was  no  tremor ;  he  could  put  right  hand  to 
mouth  without  a  quiver.  From  the  absence  of  ear-distrac- 
tion he  seemed  much  brighter.  Heard  watch  at  two  feet 
(right).  Nystagmus  less.  Power  in  the  two  hands  still  in 
proportion  (r.  69,  1.  66).  The  state  of  the  lower  extremity 
could  not  yet  be  certainly  determined,  as  he  had  been  kept 
quiet  in  bed  and  under  moderate  doses  of  gelsemium,  with 
a  view  to  favoring  a  maximum  shrinkage  of  the  aneurismal 
sac. 

March  20,  1895.  Some  local  pulsation,  especially  under 
right  ear,  though  scarcely  as  much  as  on  left.  The  thrill 
is  audible  behind  right  ear  ;  the  notch  there  is  even  more 
palpable. 

Cough  disturbs  his  head,  making,  especially  on  left  side 
of  head,  "a  dragging  feeling,"  whatever  that  may  mean. 
His  head,  when  sitting  quietly,  vibrates  or  oscillates  back 
and  forth  quite  noticeably  with  each  pulsation.  The  left 
hand  is  again  somewhat  purple  and  cooler  than  the  right. 
The  tremor  of  right  hand  has  increased  again  a  trifle, 
though  still  but  slight.  He  can  walk  alone,  though  the 
right  leg  is  the  poorer,  at  least  there  is  some  twist  and 
hitch  in  gait.  More  headache  ;  worse  when  lying  down  ; 
after  fifteen  or  twenty  minutes  such  a  dizzy  ache  he  can 
hardly  sleep  ;  still,  to-day  all  his  symptoms  are,  he  says, 
mending  again. 

As  to  his  prospects  for  the  future,  all  depends  on  a 
recurrence  of  the  aneurism.  There  is  the  possibility  that 
a  quiet  life  or  eventually  further  ligations  may  control  it. 
In  any  event,  the  case  remains  one  of  great  clinical  interest. 


XVIII. 

APOPLEXIES  OF  THE  BRAIN.  THE  IMPORTANCE  OF  EARLY 
TREATMENT  BASED  ON  THE  DIFFERENTIAL  DIAGNOSIS 
OF  THE  SEVERAL  FORMS  (HEMORRHAGE,  EMBOLISM, 
THROMBOSIS,   PSEUDO-SEIZURES)  .* 

Perhaps  evolution  has  not  kept  pace  with  the  augmented 
demands  on  our  brain-vessels.  At  least  there  is  an  im- 
pression that  troubles  of  this  kind  are  more  prevalent  than 
in  primitive  times.  Be  that  as  it  may,  the  subject  of  their 
medical  care  is  well  worth  attention. 

The  causes  and  prophylaxis  of  apoplexy  are,  to  some 
extent,  understood  ;  but  there  seems  to  be  a  lack  of  any 
promising  or  systematic  line  of  treatment  when  actual 
trouble  begins.  We  all  know  the  uselessness  of  incisive 
measures  in  cases  of  this  class  after  the  condition  has  be- 
come fully  established.  As  it  is  at  this  stage  that  the  spe- 
cialist is  usually  called  in,  it  is  the  more  important  that  the 
proper  course  to  adopt  at  the  beginning — the  only  time 
when  there  is  hope  of  our  being  of  great  service — should 
be  understood  by  the  profession  as  generally  as  possible. 
For  in  a  considerable  proportion  of  cases  invaluable  help  can 
be  rendered  if  the  physician  first  called  is  familiar  with  the 
requirements.  I  know  full  well  how  often  we  are  too  late, 
or  at  best  unable  to  accomplish  much,  and  yet  in  very 
many  cases  we  can,  if  duly  alert,  be  of  service  ;  and  even 

*  Read,  in  part,  before  "The  Medical  Club,"  Brooklyn,  June  24,  1895. 

149 


150  CENTRAL   NERVOUS   SYSTEM. 

though  the  full  evil  be  accomplished  before  our  arrival,  it 
is  safer  to  proceed  on  the  basis  that  it  is  not  so. 

Many  say,  What  is  the  use,  the  patient  is  sure  soon  to 
have  a  relapse  ?  But  this  is  not  so  certain  ;  the  person  may 
still  be  good  for  years  of  activity.  And  while  the  average 
of  expectation  in  such  an  individual  may  be  short,  it  should 
be  remembered  that  one  year  at  this  usually  mature  time 
of  life  is  often  of  more  account  to  the  dependent  family  than 
a  decade  of  youth.  In  any  case,  however,  our  duty  is  be- 
yond question. 

The  plan  of  treatment  here  proposed  is,  for  each  type, 
one  of  strict  rationalism,  and  depends  on  simple  mechanical 
principles.  The  application  of  these  may  not  be  new  in 
any  regard  ;  and  yet  the  errors  met  in  practice,  and,  still 
more,  the  wild  and  useless  recommendations  that  we  so 
often  see  advocated  in  print,  suggest  that  some  one  ought 
to  make  a  systematic  presentation  of  what  can  be  done  and 
how  to  do  it.  Many  of  our  therapeutic  attempts  are  based 
on  the  blind  action  of  remedies  or  drugs  that,  even  if  active, 
may  or  may  not  accomplish  some  indirect  result  that  we 
desire.  Here  we  have  an  important  field  in  which  we  can 
work  on  clear  lines,  for  a  definite  purpose,  and  with  con- 
trollable but  positive  means. 

It  is  proposed  to  take  up  specifically  but  the  four  classes  of 
cases.  What  I  have  to  say  is  based  on  my  own  observations, 
and  every  point  I  believe  I  have  had  opportunity  to  verify  in 
practice.  One  unfortunate  fact  often  limits  the  exactness  of 
our  knowledge  in  these  matters,  and  that  is  the  difficulty  of 
getting  autopsies. 

DIAGNOSIS. 

The  first  matter  in  any  given  case  is  an  exact  differ- 
ential diagnosis  between  the  conditions  under  consideration. 


CENTRAL   NERVOUS   SYSTEM.  151 

Upon  this  depends  all  our  hope  of  usefulness,  since  they  call, 
in  part,  for  directly  opposite  lines  of  treatment.  Unfor- 
tunately, the  means  of  distinguishing,  especially  in  such 
emergency  cases,  are  inadequate.  I  can  mention  but  a 
few, — for  the  most  part  but  little  recognized  in  the  books, 
and  some  of  which  deserve  a  more  careful  consideration ; 
even  though  "adventitious"  symptoms,  they  are  of  the 
highest  importance, — and  emphasize  the  necessity  of  good 
medical  judgment.  To  know  our  patients,  their  past  his- 
tories, and  any  chronic  disorders  from  which  they  may  be 
suffering,  is  more  than  half  the  battle. 

With  us  hemorrhage  seems  to  be  the  most  frequent 
form,  although  from  studies  elsewhere  this  may  be  more 
apparent  than  real. 

Its  occurrence  under  forty  years  of  age  has  been  sup- 
posed to  indicate  embolism,  and  over  forty,  hemorrhage. 
Yet  there  are  too  many  exceptions  to  allow  much  value  to 
any  such  age-rule.  Gowers  (''Clinical  Lectures,"  1895,  p. 
57)  says,  "These  two  [embolism  and  thrombosis  from  syph- 
ilitic disease,  as  causes  of  hemiplegia]  embrace  certainly 
ninety-five  per  cent,  of  the  cases  of  sudden  onset  in  early 
adult  life." 

Renal  disease  with  its  arterial  changes  may  cause  hem- 
orrhage, often  false  attacks  of  uraemic  nature,  less  often 
thrombosis,  but  not  of  itself  ever  embolism. 

It  is  doubtful  if  an  excess  of  adipose,  either  general  or 
especially  about  the  neck,  has  any  relation  to  the  rupture 
of  encranial  vessels, — the  sparest  physique  is  no  guarantee 
of  immunity.  On  the  contrary,  I  have  so  often  seen  it 
occur  in  frail  females  (emaciation  not  due  to  nephritis)  that 
there  must  be  some  very  opposite  factor  in  play.  Dr. 
Matthews,  of  Brooklyn,  suggested,  apropos  of  such  a  case, 


152  CENTRAL   NERVOUS   SYSTEM. 

an  old  principle  as  affording  a  reasonable  explanation, — 
the  ex-vacuo  theory.  The  brain-vessels  in  such  a  person 
lack  the  necessary  support  that  they  have  in  a  well-nour- 
ished individual,  and  so  in  time  give  way.  This  view  is 
borne  out  in  my  experience  by  the  fact  that  in  such  a 
person  the  hemorrhage  when  once  started  has  always  been 
a  very  large  one  (no  counter-pressure  to  check  the  outflow). 
The  principle  may  help  us  to  understand  such  cases,  though 
it  affords  no  material  assistance  in  making  a  differential 
diagnosis. 

It  has  been  suggested  that  the  onset  on  rising  in  the 
morning  may  be  of  diagnostic  value.  Its  occurrence  at 
this  time  is  not  very  rare,  though  it  is  not  always  possible 
to  ascertain  definitely  whether  or  not  it  existed  before  first 
rising.  At  the  instant  of  assuming  the  upright  position 
there  is  a 'sudden  letting-down  of  the  brain-current,  suffi- 
cient in  a  weak  person  to  produce  symptoms  of  fainting. 
To  that  extent  thrombosis  would  be  favored.  But  this 
stage  is  too  temporary  by  itself  to  cause  that  result,  and 
is  followed  by  an  increase  in  the  heart's  action  and  a 
heightening  of  the  blood-pressure.  An  embolus  might  be 
set  going  or,  more  likely,  a  vessel  ruptured. 

If,  however,  the  condition  was  found  before  rising,  the 
probability  would  be  thrombosis  or  hemorrhage, — embolism 
not  impossible,  but  only  unlikely. 

In  persons  who  have  had  spontaneous  hemorrhages  else- 
where, as  under  the  conjunctiva,  there  is  a  natural  inclina- 
tion to  make  a  diagnosis  of  like  cerebral  effusion.  But  I 
have  seen  this  very  occurrence  followed  soon  after  by 
evident  cerebral  thrombosis  with  continued  inclination  to 
recur. 

Several  medical  friends  have  related  to  me  cases  in  their 


CENTRAL   NERVOUS   SYSTEM.  153 

practice  where  the  onset  of  an  apoplexy  was  at  the  time  of 
coitus.*  These  few  cases  seem  always  to  have  been  in  the 
male  ;  but  like  attacks  in  the  female,  and  apparently  of 
cerebral  origin,  are  now  and  then  heard  of.  It  is  clear 
that  the  greatly  heightened  vascular  tension  during  this  act 
would  prevent  any  thrombosis  at  the  time.  An  embolus 
might  be  swept  off,  but  the  probabilities  are  strongly  in 
favor  of  hemorrhage  in  such  an  event. 

Straining  at  stool  is  an  occasional  cause.  This  ought 
likewise  not  to  favor  embolism.  It  might  permit  throm- 
bosis, though  its  special  tendency  would  be  towards  vascular 
tearing  and  hemorrhage. 

The  occurrence  of  vomiting  is  common,  and  strongly 
suggestive  of  hemorrhage,  but  not  of  embolism  or  throm- 
bosis. Nausea,  of  course,  may  attend  nephritis,  and  dizzi- 
ness, faintness,  etc.,  occur  in  thrombosis  ;  but  real  vomiting, 
aside  from  uraemia  (the  person  being  in  a  prone  position), 
argues  in  a  suspicious  case  for  hemorrhage.  Of  course, 
any  existing  kidney-trouble  augments  both  hemorrhage 
and  nausea.  In  fact,  vomiting  is  one  of  the  most  important 
and  decisive  symptoms.  This  applies  to  the  increasing 
period  of  the  hemorrhage.  Where  the  latter  is  at  all  volu- 
minous, in  almost  any  part  of  the  brain,  we  get  vomiting, 
severe  and  often  somewhat  prolonged.  Its  occurrence  de- 
pends (aside  from  personal  idiosyncrasy)  upon  the  volume 
of  the  effusion,  still  more  upon  the  speed  with  which  it  is 
poured  out,  and  to  some  extent  also  upon  its  location.  In 
the  slower  or  ingravescent  forms,  even  though  they  finally 
reach  a  large  size,  there  is  much  less  tendency  to  emesis. 


*  An  occurrence  long  since  discussed  by  Bertini,   Gior.  d.  Soc.  Med.-chir. 
di  Torino,  1843,  vol.  xvi.  pp.  67-69. 


154  CENTRAL   NERVOUS   SYSTEM. 

It  is  only  where  we  find  other  evidence  of  an  apoplectic 
seizure  that  this  symptom  is  of  value,  and  then  chiefly  in 
differentiating  the  nature  of  the  brain-process. 

Nearly  always  some  other  plausible  explanation  of  the 
vomiting  is  proffered.  The  person  has  just  eaten  over- 
heartily,  or  been  lying  in  a  cramped  position,  or  had  a 
hypodermic,  or  taken  medicine  that  upset  the  stomach,  or 
been  suffering  from  gastric  catarrh.  The  regularity  and 
persistency  with  which  this  manifestation  in  these  cases  is 
misinterpreted  is  almost  pathognomonic. 

When  the  condition  develops  during  sleep  the  probabili- 
ties are  against  embolism.  It  may  be  a  hemorrhage,  while  it 
is  a  favorite  time  for  thrombosis,  thanks  to  the  ebb  in  circu- 
lation. 

A  history  of  past  rheumatism,  especially  the  presence  of 
a  heart-murmur,  and  sometimes  a  knowledge  of  previous 
vascular  plugging  (immaterial  in  what  part  of  the  body), 
speak  for  embolism.  Says  Gowers,  /.  c,  p.  55,  "To  jus- 
tify a  diagnosis  of  embolism  you  must  find  a  source, — 
that  is,  practically  you  must  find  valvular  disease  of  the 
heart  ;  or,  if  the  attack  occurred  some  months  ago,  you 
must  have  a  history  of  some  malady,  not  long  before  the 
onset,  known  to  cause  endocarditis."  This  ignores  cases 
due  to  the  breaking  down  of  atheromatous  patches,  oftener 
transient. 

Usually  embolic  symptoms  develop  suddenly  and  are 
soon  complete,  this  giving  a  very  useful  diagnostic  help, 
though  they  may  deepen  for  hours  after  the  onset. 

Gowers,  /.  c,  p.  58,  "Loss  of  consciousness  at  the 
onset  is  chiefly  important  when  the  distinction  has  to  be 
made  between  hemorrhage  and  softening.  In  the  latter  it 
is  more  often  absent  than  present.  .  .  .  The  only  help  it 


CENTRAL   NERVOUS   SYSTEM.  1 55 

gives  is  that  it  is  rather  more  often  absent  in  thrombosis 
than  in  embolism,  because  the  latter  is  more  violently  sud- 
den." Embolism  is  somewhat  less  liable  to  cause  coma  ; 
at  any  rate,  the  deep  stertorous  condition.  I  have  else- 
where shown  {Medical  News,  February  18,  1888)  that  em- 
bolism limited  to  the  pallium  (cortex  and  centrum  ovale)  is 
not  attended  by  coma.  Slowly  developing  or  late  loss  of 
consciousness  speaks  somewhat  against  embolism  and  sug- 
gests a  vast  hemorrhage  or  progressing  thrombosis,  resp.,  of 
course,  inflammation. 

Previous  headaches,  apparently  in  relation  to  the  present 
trouble,  count  against  embolism. 

Yawning,  and  especially  sighing,  at  times  in  respiration 
are  very  frequent  and  noticeable  symptoms  in  hemorrhage, 
and  also  in  thrombosis  and  its  precedent  conditions.  There 
is  a  slight  parallelism  between  this  and  the  vomiting.  These 
manifestations  are  often  more  marked  if  the  person  sits  up. 
But  unfortunately  they  have  but  a  limited  value,  as  the  em- 
bolic subject  often  has  a  heart  so  damaged  that  the  same 
evidence  of  brain-anaemia  will  be  presented. 

Excessively  warm  weather,  a  rapid  rise  in  the  atmos- 
pheric temperature,  and  very  likely  marked  fall  of  the 
barometric  pressure  greatly  favor  the  occurrence  of  throm- 
bosis, while  opposed  to  hemorrhage. 

That  the  heated  term  through  its  general  debilitating 
action  favored  sinus-thrombosis  in  children  has  long  been 
known.  My  observations  indicate  that  such  meteorological 
conditions  also  greatly  favor  arterial  thrombosis  in  adults, 
though  in  a  different  manner.  The  debilitating  influence 
may,  of  course,  be  a  part  factor.  There  is  a  more  im- 
portant one,  so  far  as  the  arteries  are  concerned,  in  the 
dilatation    of    the   peripheral   circulation   with    consequent 


156  CENTRAL   NERVOUS   SYSTEM. 

drawing  away  from  the  brain,  and  coincident  with  this  the 
general  enervating  effect  of  a  heated  atmosphere. 

Prolonged  and  wavering  prodromata,  especially  if  diffuse 
or  scattering  and  not  focal,  past  syphilis,  debility,  and  ex- 
haustion also  suggest  thrombosis.  The  unilateral  type  of 
paraesthesiae,  especially  where  not  continuous  and  coming 
on  in  an  elderly  person,  possibly  accompanied  by  some 
dizziness  and  slight  nausea,  is  strongly  suggestive  of  threat- 
ening thrombosis. 

It  was  long  supposed  that  these  peculiar  tinglings,  etc. 
(pallor,  headache,  dizziness,  fulness  in  the  head,  visual 
obscuration,  nausea,  numbness  of  one  side),  pointed  to 
impending  hemorrhage.  Of  late,  owing  to  inability  to 
account  for  such  premonitions,  there  has  been  a  disinclina- 
tion to  recognize  any  connection  of  the  kind.  In  view  of 
the  evidence  of  a  vaso-motor  influence,  as  given  in  the 
chapter  on  symmetrical  brain-hemorrhages,  it  is  probable 
that  local  paralysis  of  vessels  with  sufficient  dilatation  to 
irritate  adjacent  tracts  may  precede  the  actual  rupture. 
This,  however,  is  usually  more  continuous,  and  ends  within 
a  few  days  in  a  frank  attack  of  apoplexy.  If  before  senility 
it  is  also  more  suggestive  of  threatening  rupture. 

"Atheroma  is  a  disease  of  the  old,  even  more  emphati- 
cally than  is  hemorrhage,  for  in  extreme  old  age  it  becomes 
the  more  common  lesion  of  the  two."    Gowers,  /.  c,  p.  57. 

The  physiologically  recurring  waves  of  vessel-contraction 
and  diurnal  or  other  periods  of  fall  in  pressure,  added  to 
the  pathological  narrowing  of  the  vessel  (where  there  is 
danger  of  thrombosis),  may  evidently  for  a  time  limit  the 
nourishment  in  the  respective  area  sufficiently  to  injure  its 
function  without  actually  causing  necrosis.  The  tissues  are 
still  supplied  with  enough  to  keep  them  alive,  and  as  soon  as 


CENTRAL   NERVOUS   SYSTEM.  157 

the  flow  again  increases  these  resume  their  functions.  Pres- 
ently, however,  if  relief  is  not  obtained,  the  matter  goes  too 
far  and  irreparable  softening  ensues. 

Gowers,  /.  c,  p.  56,  "Thrombosis  has  two  causes.  It  is 
a  clotting  of  the  blood,  and  it  may  be  due  only  to  a  strong 
tendency  of  the  blood  to  clot.  This,  however,  is  rare.  It 
occurs  in  the  old  and  gouty  ;  it  occurs  in  the  subjects  of 
cancer ;  it  occurs  in  states  of  profound  general  weakness  ; 
and  it  occurs  especially  soon  after  childbirth,  when  the 
vessels  of  the  uterus  have  to  be  closed  by  clot.  .  .  .  The 
second  cause  of  thrombosis  to  which  we  are  reduced  is 
disease  of  the  artery  at  the  spot,  disease  which  induces 
formation  of  the  clot." 

Thrombosis  is  largely  secondary  to  alterations  in  the 
coats  of  the  vessels.  So  the  syphilitic  form  is  hardly  a 
simple  deposit  from  the  blood.  It  may  be  essentially  a 
blocking  by  thickening  of  the  arterial  well  [in  specie  of  the 
intima).  But  clinically,  and  to  some  extent  practically,  it  is 
the  same  thing.  There  may  be  distinguishing  marks,  and, 
of  course,  a  knowledge  of  antecedent  specific  trouble  is 
important.  In  my  experience,  despite  some  authorities, 
the  process  tends  to  involve  many  vessels  or  branches 
either  at  the  same  time  or  in  succession.  Its  purely  pas- 
sive phenomena  may  also  irregularly  rise  and  fall  for  some 
time,  as  just  pointed  out, — one  day  or  part  of  a  day  present, 
then  abating  and  recurring.  One  picture  of  this  kind  re- 
sembles the  condition  termed  astasia-abasia.  The  patient, 
for  instance,  cannot  read  long  without  blurring  or  loss  of 
concentration  (dyslexia)  ;  cannot  talk  without  presently  get- 
ting a  word  wrong,  or,  more  often,  failing  to  command  the 
language  desired.  In  attempting  to  write,  the  head  soon 
rebels  and  little  errors  creep  in  ;  long  calculation  or  accus- 


158  CENTRAL   NERVOUS   SYSTEM. 

tomed  continuous  thinking  is  impossible,  and  much  muscu- 
lar exertion  soon  tires.  And  yet  there  is  no  paralysis  nor 
real  paresis,  nor  falling  out  of  any  function.  The  centres 
act  normally  for  a  brief  period,  then  play  out*  This  may 
apply  to  large  areas  or  almost  the  whole  brain,  again  is 
more  one-sided  or  even  further  limited.  Occasionally  in 
persons  of  some  intellectuality  it  is  quite  possible  to  locate 
the  phenomena  in  the  field  of  one  or  more  arteries,  prefer- 
ably the  sylvian  or  its  branches.  In  this  specific  form, 
which  may  occur  at  almost  any  period  of  life,  there  may, 
or  oftener  may  not,  be  much  headache ;  if  especially  noc- 
turnal, so  much  the  more  in  evidence.  In  other  forms  of 
trouble  here  considered  preceding  headache  is  not  rare. 

The  fact  that  compression  of  the  carotids  may  aggravate 
existing  symptoms,  and  even  bring  on  slight  convulsions  in 
persons  suffering  from  arterio-sclerosis  or  other  impairment 
of  the  brain-circulation  (Naunyn  and  others),  suggests  it  as 
an  expedient  in  the  diagnosis  of  thrombosis.  But  as  it  must 
tend  to  affect  disadvantageously  such  a  patient's  cerebral 
condition,  and  possibly  involve  injury  to  the  carotids,  it 
should  be  resorted  to  only  with  great  care. 

There  are  two  other  classes  of  cases  in  which  hemiplegia 
results  where  it  is  desirable  to  have  more  exact  knowledge, 
— viz.,  those  following  (1)  infectious  diseases  ;  (2)  acci- 
dents. 

Applying  the  facts  brought  together  by  J.  J.  Thomas 
("  Diphtheritic  Hemiplegia,"  Am.  Jml.  Med.  Sci,  April, 
1896),  we  must  conclude  that  those  resulting  from  infec- 
tions may  be  either  hemorrhagic,  embolic,  or  thrombotic. 


*  This  is  quite  distinct  from   the  prolonged,  dazed,   stuporous    condition 
sometimes  seen  in  younger  iemales  with  active  syphilis. 


CENTRAL   NERVOUS   SYSTEM.  1 59 

The  other  form,  that  supervening  some  time  after  acci- 
dents, is  considered  in  a  special  chapter. 

Assuming,  now,  that  the  diagnosis  is  made,  we  can  take 
up  the  treatment  of  each  form. 

I.    HEMORRHAGE   OF  THE  BRAIN. 

In  these  cases  there  is  a  wide  range  as  to  location,  size, 
and  tendency  to  spontaneous  cessation.  Some  are  promptly- 
fatal,  meningeal  and  ventricular  forms  being  usually  of  this 
kind.  Nearly  always,  however,  as  pointed  out  by  Liddell, 
the  effusion  progresses  for  some  time.  In  numerous  cases 
the  ingravescent  type  is  approached,  and  just  to  that  extent 
there  is  time  in  which  we  can  act.  Even  if  the  outflow  has 
already  stopped,  it  is  right  to  make  this  doubly  sure,  and 
head  off  any  early  recurrence. 

Our  efforts  sliould  be  directed  to  a  lowering  of  the  arterial 
pressure,  and  to  a  deviation  of  the  blood-current  to  other  parts, 
— i.e.,  in  general  to  a.  reduction  of  the  supply  to  the  brain. 

There  are  several  available  and  trusty  methods  of  accom- 
plishing this, — 

(i)  Position  of  the  Patient.  Some  have  recommended 
lying  with  the  head  low,  while  a  New  York  colleague  has 
advocated  the  erect  posture,  and  Heidenhain  (1890)  the 
attitude  of  sitting.  The  main  essential  is  a  sufficiently  prone 
attitude  to  insure  a  complete  relaxing  of  all  the  muscles, 
since  we  know  that  all  muscular  effort  tends  to  increase 
the  arterial  tension.  And  independent  of  the  play  of  the 
muscles,  the  blood-pressure  is,  I  believe,  known  to  be 
greater  in  the  erect  posture.  Granted,  then,  the  reclining 
position,  shall  the  head  be  dropped  or  kept  moderately 
elevated  ?  A  little  observation  of  the  ways  of  mankind 
suffices  to  furnish  an  answer.     Persons  suffering  from  simple 


160  CENTRAL   NERVOUS   SYSTEM. 

anaemia  and  exhaustion  naturally  sleep  with  the  head  low, 
this  evidently  favoring  the  brain-supply.  And  every  sur- 
geon knows  that  to  resuscitate  a  patient  the  first  thing  is  to 
lower  the  head.  On  the  other  hand,  persons  with  an  over- 
active brain-circulation  sleep  with  the  head  high,  sometimes 
lowering  it  towards  morning  as  the  pressure  subsides  (v. 
"The  Morning  Headache  of  Exhaustion,"  Brkn.  Med.JrnL, 
1 891,  p.  40).  In  heart-lesions  also,  doubtless  to  modify  the 
shock  of  each  beat  and  to  pass  the  blood  from  chest  and 
head  to  dependent  parts,  the  sufferer  courts  a  higher  eleva- 
tion of  the  head.  These  facts  are  so  clear  and  convincing 
as  to  settle  the  question  of  attitude, — unless,  of  course,  to 
meet  the  exigencies  of  some  unusual  circumstance. 

In  conclusion,  then,  the  favorite  position  for  a  patient 
with  progressive  cerebral  hemorrhage  should  be  with  the 
body  sufficiently  reclining  to  be  fully  relaxed  and  the  head 
considerably  elevated. 

Other  matters  of  posture  may  need  attention.  The 
vomiting  in  such  a  case  appears  to  be  eased  by  turning  the 
person  on  the  right  side  ;  the  thought  being  to  thus  favor 
the  natural  discharge  of  the  stomach  into  the  intestine. 
Certainly  the  vomiting  act  in  itself  must  greatly  tend  to 
increase  the  cerebral  outflow.  But  Robert  L.  Bowles  advo- 
cates turning  the  patient  over  on  the  paralyzed  side  to  ease 
stertor. 

(2)  Vaso-drugs.  The  proper  use  of  these  remedies  is 
probably  the  most  valuable  single  resource  we  have.  Of 
course,  ergot  is  generally  discarded, — no  one  ever  really 
found  out  whether  it  did  harm  or  good.  In  the  cardio- 
vascular depressants — gelsemium,  veratrium,  aconite,  or 
possibly  pilocarpine — we  have  a  means  powerful  enough  to 
suit  any  one,  effective  and  yet  ordinarily  safe.      My  own 


CENTRAL   NERVOUS   SYSTEM.  l6l 

preference  is  for  gelsemium,  very  likely  because  of  its 
greater  general  paralyzing  action.  This  ought,  doubtless, 
for  its  quickest  effect,  to  be  used  hypodermically,  though  it 
acts  promptly  by  the  mouth.  The  fluid  extract  can  be 
started  in  adults  with  an  initial  dose  of  two  to  five  drops 
and  followed  by  drop-doses  at  intervals  dependent  on  the 
closeness  with  which  the  case  can  be  watched.  It  should 
be  pushed  until  its  physiological  action  is  manifest,  whether 
little  or  much  is  required.  For  the  time  paralyze  your 
patient.  There  may  be  contra-indications  as  regards  the 
use  of  these  drugs,  but  I  have  rarely  had  occasion  to  heed 
them  in  such  cases. 

When  medication  on  this  line  has  to  be  continued  for 
any  length  of  time,  however,  it  may  be  necessary  to  change, 
especially  from  full  doses  of  gelsemium.  Then  the  others 
become  useful.  Veratrium  is  next  in  order  ;  and  both  be- 
cause of  the  more  general  familiarity  of  the  profession  with 
this  drug,  and  of  our  knowledge  of  its  safety  from  the 
ample  experience  of  its  use  in  puerperal  eclampsia,  it  will 
with  most  practitioners  prove  the  most  acceptable  remedy 
right  from  the  start. 

It  is  usually  advisable  to  keep  up  some  influence  of  this 
kind  from  a  couple  of  days  to  a  week  at  least. 

Be  careful,  on  the  contrary,  to  avoid  all  stimulants,  vas- 
cular tonics,  morphine  (resp.  any  opiate  of  this  class),  and, 
for  the  time,  strychnine.  Digitalis  I  have  repeatedly  known 
to  bring  on  a  recurrence  a  few  days  after  the  primary  at- 
tack. The  use  of  nitroglycerin  in  the  developing  stage 
of  brain-hemorrhage  almost  certainly  does  harm,  and  should, 
for  this  particular  purpose,  be  abandoned. 

The  possibility  of  increasing  the  coagulability  of  the  blood 
by  internal  drugs  is  as  yet  visionary. 


1 62  CENTRAL  NERVOUS   SYSTEM. 

(3)  Constriction  of  the  Extremities.  This  is  a  very 
promptly  acting  but  temporary  expedient  with  many  lim- 
itations. Care  must  be  had  that  the  vessels  are  not  so 
brittle  as  to  be  injured  by  the  compression,  that  just  suffi- 
cient force  is  used  to  more  or  less  shut  off  the  veins  without 
affecting  the  arteries  (if  too  much  we  but  strangle  the  ex- 
tremity, if  too  little  we  fail  of  our  purpose),  that  the  respec- 
tive extremities  do  not  become  too  cold,  and,  finally,  that 
the  constriction  be  eased  up  very  gradually  lest  the  sudden 
influx  into  the  general  circulation  again  start  up  the  very 
trouble  we  are  seeking  to  control.  Warm  bottles  at  the 
extremities  and  gentle  frictions  are  of  themselves  useful  in 
drawing  blood  to  the  parts,  and  are  doubly  so  when  con- 
striction is  used. 

The  recently  vaunted  compression  of  the  carotids  is  a 
doubtful  therapeutic  measure  (its  possibilities  for  diagnostic 
purposes  have  already  been  considered),  as  the  vessels  in 
these  patients  are  often  easily  injured,  a  steady  control  of 
the  current  for  any  length  of  time  is  rarely  possible,  and 
the  frequent  jets  that  do  get  by  the  compressor's  fingers 
must  wonderfully  tend  to  displace  any  occluding  clot  at 
the  point  of  rupture.  Ligature  of  a  carotid  seems  a  still 
more  crazy  and  quite  unnecessary  procedure. 

Ice  to  the  head  is  a  very  popular  plan,  but  also  of  very 
uncertain  value.  Probably,  if  used  at  all  for  the  purpose,  the 
ice  might  far  better  be  applied  over  the  carotids  in  the  neck. 

(4)  Depletion  of  Body-fluids.  Formerly  this  was  the 
main  treatment,  and  practised  in  the  form  of  venesection. 
Many  still  think  highly  of  this  for  some  cases.  The  most 
common  and  still  accepted  method  is  by  purgatives,  as  a 
drop  of  croton  oil  on  the  tongue.  Or  a  glycerin  enema 
may  be  given. 


CENTRAL   NERVOUS   SYSTEM.  1 63 

In  cases  of  threatening  rather  than  developing  hemor- 
rhage of  the  brain,  laxatives  are  most  important.  Fer- 
mentation, clogging,  etc.,  of  the  bowels  seem  at  times  an 
immediate  cause,  and  then  calomel  is  particularly  in  place. 
Pilocarpine  might  be  admirable,  since  it  acts  both  as  a 
depressant  and  as  a  fiuid-depletor,  but  for  certain  risks,  as 
of  pulmonary  oedema. 

It  will  perhaps  not  be  amiss,  in  passing,  to  contrast  with 
the  foregoing  our  limited  resources  in  the  second  stage  of 
apoplexy.  For  convenience  we  can  distinguish  three  dif- 
ferent stages, — 

1st.  That  of  onset  and  development,  already  considered. 

2d.  That  of  reaction  (or  subacute). 

3d.  The  chronic,  remaining  after  all  active  processes  have 
run  their  course  (unless  the  degeneration  of  implicated 
paths). 

In  the  second  stage  there  is  still  some  shock,  an  actual 
destruction  of  brain-tissue,  a  compression  of  adjacent  tracts 
by  the  volume  of  the  extravasation,  and  an  inflammatory 
reaction  of  immediately  surrounding  parts.  It  is  largely 
the  development  of  this  last  that  constitutes  the  final  factor 
in  so  many  cases  ending  fatally  in  from  two  to  ten  days. 
Moreover,  where  life  is  retained  the  neighboring  structures 
are  by  this  reaction,  oedema,  etc.,  still  further  jeopardized, 
and  the  possible  extent  of  eventual  recovery  is  materially 
reduced. 

It  might  be  thought  that  there  would  be  more  hope  of 
late  improvement  after  hemorrhage  than  after  infarction. 
Yet  experience  hardly  bears  this  out,  the  reason  therefor 
probably  being  the  greater  reaction  surrounding  a  hemor- 
rhage. 

We    have    little    to   offset   this.      Counter-irritation    can 


1 64  CENTRAL   NERVOUS   SYSTEM. 

hardly  act  that  deeply.  Iodides  to  favor  quick  absorption 
of  clot,  and  brucia  or  its  congeners  to  support  the  viability 
of  endangered  fibres,  is  about  all.  Trephining,  with  evulsion 
of  clots,  would  be  in  order,  though  so  rarely  feasible.  Of 
course,  we  can  also  do  something  towards  warding  off  a  re- 
currence. Negatively,  the  use  of  digitalis  in  a  patient  who 
has  once  suffered  from  brain-hemorrhage  is  ever  after  a  risky 

matter. 

II.  EMBOLISM  OF  THE  BRAIN. 

The  treatment  of  this  condition  is  in  nearly  every  respect 

the  direct  opposite  of  that  for  hemorrhage.*     Three  ways 

of  relief  suggest  themselves. 

a.  The  first  is  by  the  development  of  a  collateral  circula- 
tion. But,  as  is  well  known,  certain  portions  of  the  brain 
supplied  with  terminal  vessels  are  excluded  from  such  possi- 
bility ;  and  even  the  vessels  of  the  other  parts  have  so 
limited  connections  as  to  preclude  full  compensation  where 
an  artery  of  much  size  is  stopped.  The  means  favoring  a 
development  of  collaterals  are  the  same  as  those  described 
below  {sub  c). 

b.  Another  is  by  breaking  up  the  embolus.  In  practice, 
however,  we  cannot  expect  in  any  manner  to  accelerate 
this,  except  so  far  as  it  may  be  favored  by  increased  press- 
ure and  the  act  of  tumbling  the  plug  along.  Something 
in  this  line  may  be  more  certainly  accomplished  where  the 
blockage  is  due  to  soft  atheromatous  material. 

c.  The  final  and  really  available  way  is  to  force  the  em- 
bolus as  far  along  into  some  peripheral  vessel  as  possible. 
Any  advance  is  a  great  gain.  An  inch  may  reduce  the 
area  jeopardized  to  but  a  fraction  of  its  original  extent, — 

*  Bastian  (1890)  partly  appreciates  this  when  he  notes  that  hemorrhage  re- 
quires directly  opposite  methods  of  treatment  from  embolism  and  thrombosis. 


CENTRAL   NERVOUS   SYSTEM.  1 65 

and  this  means  much  more  to  the  patient  than  such  a  ratio 
indicates.  Then  there  is  better  chance  of  the  collateral  cir- 
culation sufficing.  Hence  the  general  plan  is  to  hoist  the 
flood-gates  and  turn  on  pressure. 

1.  Sometimes  the  heart  is  beating  violently,  and  we  fear 
lest  another  plug  be  torn  off.  Or  the  patient  may  not  be 
in  good  trim  for  being  up  ;  or  many  times  the  heart  is  too 
enfeebled  to  properly  overcome  gravity.  So  that  the  wisest 
and  safest  rule  is  to  place  the  head  very  low,  even  letting  it 
be  dependent. 

2.  Here  the  nitrites  are  directly  indicated,  the  quickly 
acting  nitroglycerin  or  nitrite  of  amyl  being  best.  Then 
come  alcoholics  in  doses  to  stimulate.  Next  free  libations 
of  hot  drinks  that  may  rapidly  be  taken  up  by  the  circula- 
tion. Probably  hot  cloths  along  the  carotids  in  the  neck 
would  be  useful,  as  dilating  the  supply-tubes  of  the  respec- 
tive area. 

Avoid  scrupulously  all  depressants,  depletors,  and  such 
vascular  constrictors  as  ergot  and  digitalis.  Strophanthus 
may  be  admissible. 

Abdominal  bandaging  a  la  Leonard  Hi\l(Proc.  Roy.  Soc, 
v.  N.  Y.  Med.  JrnL,  1895,  i.  pp.  349,  350),  though  em- 
ployed by  him  for  other  conditions,  would  be  worth  using 
here.  And  even  an  Esmarch  to  one  or  more  extremities 
would  be  quite  in  order. 

For  embolism,  then,  favorable  position  of  head  and  body, 
dilatation  of  brain-vessels,  heightening  of  blood-pressure 
where  safe,  increase  of  body-fluids. 

III.  THROMBOSIS. 

This  is  a  far  more  complicated  subject,  and  the  treat- 
ment partakes  much  more  of  a  prophylactic  nature.     The 


166  CENTRAL   NERVOUS   SYSTEM. 

trouble  is  usually  of  slower  development  and  needs  be  met 
with  less  vigor  but  more  persistence.  It  is  quite  as  serious 
as  the  previous  troubles,  much  more  varied  in  nature,  and 
requires  greater  skill  in  adaptation  of  means  to  an  end. 
There  is  one  serious  danger  in  the  measures  for  relief.  We 
are  dealing  with  diseased  vessels,  their  walls  being  often 
much  weakened.  There  is  no  such  disturbing  fear  in 
embolism,  for  there  the  vessels  are  presumably  healthy, 
nor  in  hemorrhage,  for  there  our  efforts  at  relief  in- 
volve no  strain  on  the  vessels.  Just  as  I  have  seen  an 
oesophageal  stricture  cause  a  rupture  of  its  adjacent  wall, 
so  I  always  fear  in  treating  cerebral  thrombosis  lest  the 
therapeutic  efforts  bring  on  an  equally  objectionable 
hemorrhage. 

Hemorrhage  usually  and  embolism  always  is  arterial, 
while  thrombosis  may  affect  veins  or  sinuses  as  well  as  arte- 
ries. The  sinus  form  is  a  somewhat  special  matter,  following 
either  neighboring  septic  trouble  or  else  exhaustion  and 
debility,  notably  in  children,  while  thrombosis  of  cerebral 
veins  can  hardly  be  distinguished  as  an  entity  by  itself.  In 
the  arterial  form  of  adults  we  know  of  three  principal 
causes, — arterio-fibrosis  in  nephritics,  atheroma,  and  the 
end-arteritis  of  syphilis.  When  from  either  of  these  causes 
we  find  signs  of  danger  impending  or  trouble  already  pres- 
ent, the  first  or  immediate  line  of  treatment  is  analogous  to 
that  in  embolism,  though  there  is  less  need  of  increasing 
the  body-fluids.  The  vessels  must  be  dilated  to  allow  the 
blood  to  pass,  and  the  pressure  should  be  increased  to 
get  it  through.  Here,  again,  the  nitrites  are  as  yet  the 
sheet-anchor,  sometimes  reenforced  by  strophanthus  and 
strychnine.  But  there  is  a  choice.  The  nitrite  of  sodium 
or  even  of  potassium  is  the  best,  since  its  action  is  more 


CENTRAL   NERVOUS   SYSTEM.  167 

prolonged    than    that    of    the    amyl    or     glycerin    com- 
pounds.* 

Avoid  digitalis  and  everything  causing  arterial  contrac- 
tion. As  soon  as  immediate  relief  is  secured  we  must  take 
some  course  for  more  lasting  benefit. 

1st.  In  kidney-trouble  this  may  not  be  possible,  our 
treatment  there  remaining  symptomatic. 

2d.  In  atheroma  the  French  commend  small  long-con- 
tinued doses  of  iodide  of  potassium.  For  one  reason  or 
another  (slow  action,  the  occurrence  of  iodism,  etc.)  it  has 
rarely  given  much  satisfaction  in  my  experience. 

But  there  are  several  useful  lines  of  treatment  The 
nitrites  should  be  accompanied  or  followed  by  brucia  or  its 
allies  in  stout  doses  (one-twentieth  to  one-thirty-second 
of  a  grain),  and  persisted  in  for  months  with  more  or  less 
regularity  according  to  immediate  needs  at  any  time. 

Another  useful  line  of  remedies  depends  upon  the  fact 
that  most  of  these  old  patients  are  rheumatic,  gouty,  or  suf- 
ferers from  what  may  be  termed  senile  lithsemia.  Physical 
inactivity  plays  a  part.  The  waste  and  refuse  products  of 
the  system  are  not  eliminated  with  due  promptness  and 
aggravate  the  atheromatous  processes.  Here  alkalies  and 
antilithic  remedies  have  to  be  employed.  One  of  the  most 
important  aids  is  furnished  by  certain  of  the  sulphur  waters. 
If  it  is  possible  for  the  patient  to  visit  the  springs,  so  much 
the  better  ;  otherwise  the  water  may  be  employed  at  home. 


*  Bradbury,  in  a  recent  Bradshaw  Lecture  on  some  new  vaso-dilators  {Lan- 
cet, 1895,  vol.  ii.  pp.  1205-1213),  brings  experimental  proof  of  the  avail- 
ability of  erythrol  tetra-nitrate  and  mannitol  nitrate.  In  doses  of  a  grain  or 
even  more  (given  either  in  solid  form  or  dissolved  in  alcohol)  the  effect  begins 
in  half  an  hour  and  lasts  several  hours.  These  are  non-poisonous  and  do  not 
cumulatively  lose  their  action  like  nitroglycerin. 


1 68  CENTRAL  NERVOUS   SYSTEM. 

Sharon,  Massena,  or  other  waters  of  this  class  can  be  had 
in  bottles  and  used  anywhere.  The  water  should  be  taken 
up  to  a  half-pint  before  breakfast  and  supper  for  periods 
of  a  month  or  more  at  a  time.  After  an  interval  the  course 
may  need  to  be  repeated.  The  good  the  patient  experi- 
ences from  these  waters  is  often  not  limited  to  any  effect 
on  the  brain-arteries,  but  includes  a  favorable  action  on 
many  other  functions  of  the  body. 

This  use  of  these  waters  seems  to  be  little  known,  but  I 
can  commend  it  as  a  valuable  addition  to  our  means. 

In  syphilis  the  whole  power  of  our  therapeutic  resources 
should  be  forthwith  brought  to  bear,  and  continued  until 
long  after  all  symptoms  are  gone  or  all  hope  of  relief  aban- 
doned. It  should  be  borne  in  mind  that  often  the  so-called 
specifics  for  syphilis  will  develop  this  desired  local  action 
only  after  the  vessels  have  been  dilated.  When  they  are 
almost  closed,  it  is  evident  that  little  blood,  and  conse- 
quently little  of  the  medicament,  can  reach  the  imperilled 
point.  It  is  necessary,  if  possible,  to  open  the  vessel-path, 
and,  while  keeping  the  way  open,  follow  up  with  the  more 
direct  specifics. 

This  field  for  the  use  of  vaso-dilators  has  not  been  prop- 
erly, if  at  all,  recognized.  In  my  experience  their  value  is 
very  great,  and  their  effect  strikingly  satisfactory  to  patient 
and  physician.  Once  we  have  a  correct  diagnosis,  if  de- 
struction has  not  already  taken  place,  the  certainty  of  at 
least  temporary  relief  is  as  great  as  in  any  trouble  about 
which  we  are  consulted. 

As  syphilis  has  such  a  wide-spread  tendency  to  cause  arte- 
rial interference,  the  same  principle  is  applicable  in  many  of 
its  late  forms.  To  what  extent  it  will  prove  useful  in  securing 
more  effect  of  the  specifics  when  other  parts  of  the  body 


CENTRAL  NERVOUS   SYSTEM.  1 69 

are  involved  may  be  left  to  those  working  in  those  lines  to 
decide.  One  of  my  colleagues,  Dr.  Winfield,  has  adopted 
it  in  many  of  these  old  cases,  and  believes  it  to  be  a  suc- 
cess. We  all  know  that  at  times  an  undoubted  syphilitic 
process  fails  to  respond  well  to  treatment.  Some  of  these 
cases  can  be  reached  by  this  plan,  and  very  many  by  a  less 
amount  of  specifics  than  otherwise.* 

iv.  pseudo-apoplectic  seizures. 

(in   part   the   apoplexia    nervosa  and   parapoplexy  of 
older  writers.) 

Under  this  heading  might  be  included  a  great  variety 
of  conditions  due  to  fainting,  hysteria,  congestive  chills, 
toxaemias,  as  gout,  disseminated  sclerosis,  cerebral  softening 
of  unknown  origin,  etc.  But  I  refer  to  a  type  best  illus- 
trated by  the  paralytic  and  convulsive  attacks  that  not 
rarely  occur  in  the  early  course  of  paresis.  Clinically  and 
practically  there  is  quite  a  parallelism  between  these  and 

*  Recently  Petrone,  of  Naples,  induced  by  certain  chemical  considerations, 
made  a  trial  of  the  nitrite  in  syphilis  ("  Sull  'uso  dei  nitriti  nella  cura  delle  Ma- 
lattie  infettive, "  Riforma  Medica,  1895.  Agosto.  Abstr.  in  Giornale  Italiano 
delle  Alalattie  Veneree  e  della  Pelle,  September,  1895).  One  case  was  of  com- 
bined paludism  and  syphilis.  Initial  dose  of  five  to  ten  centigrammes,  in- 
creased to  a  maximum  of  half  a  gramme  daily.  This  was  given  subcutaneously 
in  solutions  of  two  to  three  per  cent., — five  per  cent,  may  be  painful.  Treat- 
ment lasted  thirty  days.  Second  case  was  a  woman  of  twenty-two  years,  with 
hereditary  syphilis.  Treatment  as  in  preceding  case  for  twenty-six  days.  Com- 
plete cure.  Sprecher,  of  Turin,  ibid.  {Giornale  Italiano,  1896,  pp.  453-456), 
found  in  twelve  cases  that  it  only  relieved  osteocopic  pains,  and  even  that 
much  with  uncertainty,  and  often  discomfort. 

But  these  observers  used  it  as  a  remedy  in  itself  for  the  disease,  and  hence  for 
a  very  different  purpose.  The  method  employed  by  me  is  first  for  temporary 
safety,  and  then  more  widely  as  a  means  by  which  to  get  better  results  from 
routine  specifics.  For  this  purpose  the  hypodermic  use  is  unsuited  ;  prolonged 
action  without  untoward  effects  is  that  here  desired. 


170  CENTRAL   NERVOUS   SYSTEM. 

certain  manifestations  of  chronic  alcoholism.  Their  correct 
recognition  may  require  our  finest  diagnostic  skill,  and  yet 
is  usually  possible  and  even  certain,  medically  speaking. 

Such  paralyses  may  be  found  in  the  morning,  yet  without 
adequate  shock  ;  or  come  on  during  waking  hours  without 
much  general  disturbance,  though  usually  attended  by  many 
distinguishing  symptoms.  They  are,  as  a  rule,  of  brief  dura- 
tion, beginning  to  improve  in  a  day  or  two.  Allied  to  these, 
and  frequently  associated  with  them,  are  the  more  common 
epileptiform  convulsions,  not  rarely  very  severe  in  character. 

The  key  to  one  line  of  rational  and  relatively  successful 
treatment  here  is  given  by  certain  pathological  findings. 
In  old  alcoholics  we  expect  the  wet  brain,  with  the  effused 
fluid  under  decided  pressure.  It  has  also  long  been  known 
that  there  was  an  excess  of  fluid  about  the  brains  of  paretics. 
Writers  call  this  ex  vacuo.  Nevertheless  the  fluid  many 
times  spurts  out  on  incising  the  dura.  If  pressure  still  per- 
sisted post-mortem,  how  much  greater  must  it  have  been 
during  life.  In  fact,  this  is  conclusive  proof  that  the  accu- 
mulation is  not  passive  to  fill  up  any  vacuum  ;  and  the  argu- 
ment must  hold  even  for  cases  where  we  have  less  evidence 
of  pressure,  despite  the  fact  that  many  of  the  authorities 
conclude  otherwise. 

Again,  the  good  that  some  operators  have  seen  follow 
trephining  in  dements  argues  against  the  vacuum  view. 

Perhaps  the  most  accepted  teaching  as  to  the  immediate 
causation  of  these  seizures  is  that  they  depend  on  local 
cerebral  cedemas  or  fluxions.  This  is  in  harmony  with  the 
above.      Hence  we  have  a  definite  basis  for  action. 

It  will  not  do  to  draw  the  blood  away  from  the  head,  as 
a  compression-anaemia  already  exists,  and  is  presumably 
the  very  cause  of  the   attacks.     We  must  get  the  fluid 


CENTRAL   NERVOUS   SYSTEM.  17  I 

away,  stimulate  its  absorption,  and  support  the  blood- 
pressure.  Diuretics,  like  iodide  of  potash,  cardiac  stimu- 
lants, like  strophanthus,  and  counter-irritation,  as  by  small 
fly-blisters  over  the  scalp  and  back  of  the  mastoids,  are  of 
grand  service.  Bromides  are  useless,  even  harmful,  though 
so  often  prescribed.  Spinal  puncture  (suggested  for  pare- 
sis by  the  writer  in  1894)  is  theoretically  indicated,  though 
in  my  experience  so  inadequate  as  to  be  almost  useless. 
Recently  Babcock  [State  Hospital's  Bulletin,  July,  1896), 
has  reported  some  benefit  from  this  procedure  in  progres- 
sive dementia;  though  J.  Turner  {Brit.  Med.  Jrnl.,  1S96, 
vol.  i.  p.  1084)  observed  practically  no  amelioration  in 
fourteen  cases. 

Trephining  with  incision  of  the  dura  is  rational,  but  any 
operation  requiring  the  administration  of  an  anaesthetic  is 
in  that  way  decidedly  objectionable. 

What  we  need  here,  as  in  several  other  troubles,  is  some 
plan  for  increasing  the  normal  absorption  of  the  fluid,  some 
improved  drainage  from  the  subarachnoid  meshes  back  into 
the  general  lymphatics. 

It  may  not  be  amiss  in  closing  to  call  attention  to  the 
need  of  common  sense  in  applying  any  remedy.  The 
special  conditions  in  some  concrete  case  may  warrant  us  in 
directly  contravening  the  best  of  rules. 

Finally,  a  given  set  of  measures  should  not  be  con- 
demned because,  unhappily,  often  inadequate  to  the  re- 
quirements If  they  are  unquestionably  rational  we  should 
use  them  for  all  they  are  worth,  and  at  the  same  time  hunt 
for  further  help. 

The  main  original  purpose  of  this  paper  was  to  show 
how  widely  the  therapeutic  indications  differed  in  these 
classes  of  cases. 


Supra-cerebral  veins  of  the  monkey. 

Fig.  2. 


Ccelian  veins  of  the  monkey.  The  basilar  is  seen  on  each  side,  coming  up  behind  the 
thalamus  ;  that  on  the  right  empties  directly  into  Galen's  vein,  while  that  on  the  left  ends  in 
the  resp.  velar.     The  choroid  vein  is  shown  on  the  right  only. 


PLATE  II. 


Fig.  3. 


Spheno-temporal  emissary  in  the  monkey  ;  indicated  by  the  white  line. 


Fig.  4. 


Outline  of  cranial  fissure  and  depression  in  the  case  of  old  traumatic  cephalhydrocele. 


)T    * 

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